Quick ethics question

[Phloston]

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Let's say a patient has a living will that he had written two years ago that says he does not want life-saving Tx if he is to lose consciousness.

So now let's say he has an accident at home and he tells his wife that he has changed his mind and now wants all efforts to be made to save him if he loses consciousness.

The patient then loses consciousness at the hospital.

The living will says one thing but the wife says the opposite.

Ordinarily, the living will should come before the next of kin (i.e. wife) given that she has presumably not been appointed as his durable power of attorney.

What is the appropriate action here?

 

[Ronin786]

Call in the ethics committee!


In all seriousness I would assume the wife would overrule. I recall a question that was slightly similar and the answer was that when the wife is telling you what her husband says she's simply an extension of his wishes as opposed to a surrogate making a decision for him. So his wishes would override the will I think.

That would all be assuming that the wife isn't lying, but within the context of a Step 1 question I don't think she would.

 

[thehundredthone]

Let's say a patient has a living will that he had written two years ago that says he does not want life-saving Tx if he is to lose consciousness.

So now let's say he has an accident at home and he tells his wife that he has changed his mind and now wants all efforts to be made to save him if he loses consciousness.

The patient then loses consciousness at the hospital.

The living will says one thing but the wife says the opposite.

Ordinarily, the living will should come before the next of kin (i.e. wife) given that she has presumably not been appointed as his durable power of attorney.

What is the appropriate action here?

A. His last verbal directive overrules any existing documentation.
B. His wife does not need durable power of attorney, she is the natural surrogate (eldest child would come next). However, anyone apart from his wife would need a DPOA to overrule the wife.

So you have to make all efforts to save him.

 

[Phloston]

A. His last verbal directive overrules any existing documentation.
B. His wife does not need durable power of attorney, she is the natural surrogate (eldest child would come next). However, anyone apart from his wife would need a DPOA to overrule the wife.

So you have to make all efforts to save him.

So if the guy, before losing consciousness, had told his adult son that he changed his mind and wants efforts made to save him, but his wife says he wouldn't want to be saved, what should be done? Because the patient's word should technically come before the wife's.

Would it be: ethics committee --> wife's decision still stands?

Because otherwise it's a slippery slope and anyone could technically say the patient had said this or that, and then the whole hierarchy collapses.

 

[thehundredthone]

It always comes down to who represents the patient's wishes. If the adult son says that his father had expressed a wish to be resuscitated if the time came then that is taken as the patient's directive over what the wife thinks should be done (note: in her opinion, not a reflection of the patient's wishes). The DPOA would be for relatives like a sister, who wouldn't be high up in the pecking order.

If both claimed to know what the father wanted and both said different things, it would be on a soap opera and not on the USMLE, probably.

This is all purely for the exam's purposes, mind you.

 

[ijn]

Consults or ethics committees are always the wrong answer on STEP 1. Don't fall into that trap. The test writers want you to take action.

The most recent wishes of a patient always take precedence. Your job isn't to determine if the son is being truthful.

 

[RedSoxSuck]

Consults or ethics committees are always the wrong answer on STEP 1. Don't fall into that trap. The test writers want you to take action.

The most recent wishes of a patient always take precedence. Your job isn't to determine if the son is being truthful.

Yea, i agree with ijn. I remember from kaplan videos that reason why calling in a committees answer is wrong is because they want YOU to be able to handle crisis and want YOU to be competent enough to make the call while obeying the rules/regulations etc. Best answer would be to listen to his wife because its MORE RECENT (two days ago). And it seems, he was competent 2 days ago to give his wife CLEAR directions regarding life saving treatments.

 

[RedSoxSuck]

Call in the ethics committee!


In all seriousness I would assume the wife would overrule. I recall a question that was slightly similar and the answer was that when the wife is telling you what her husband says she's simply an extension of his wishes as opposed to a surrogate making a decision for him. So his wishes would override the will I think.

That would all be assuming that the wife isn't lying, but within the context of a Step 1 question I don't think she would.

This would be marked incorrect. No questions asked.

 

[RedSoxSuck]

Call in the ethics committee!


In all seriousness I would assume the wife would overrule. I recall a question that was slightly similar and the answer was that when the wife is telling you what her husband says she's simply an extension of his wishes as opposed to a surrogate making a decision for him. So his wishes would override the will I think.

That would all be assuming that the wife isn't lying, but within the context of a Step 1 question I don't think she would.

This would be marked incorrect. No questions asked.

You gotta be sharp, competent and "edgy" like Mr. Spector and not a tool like hardmon or Mr. Litt

 

[Ronin786]

This would be marked incorrect. No questions asked.

You gotta be sharp, competent and "edgy" like Mr. Spector and not a tool like hardmon or Mr. Litt

I was joking about the ethics committee. Thought it was a bit more obvious, sorry.

I would give up a lot to be like Harvey Specter. Or Mike Ross, he'd nail Step 1.

 

[thehundredthone]

I was joking about the ethics committee. Thought it was a bit more obvious, sorry.

The guy just gave his Step 1 a week (plus 3 years) ago, you've gotta go a little easy on him. I think the order of return to senses is time, then sense of humour.

 

[RedSoxSuck]

The guy just gave his Step 1 a week (plus 3 years) ago, you've gotta go a little easy on him. I think the order of return to senses is time, then sense of humour.

True.. I have lost my orientation to time place and person. Plus I'm sick of watching catheter commercials on day time tv. Even ESPN for crying out loud.

 

[thehundredthone]

Only in America? I don't know, I haven't watched TV in a long time now, mostly because I don't have a cable connection where I stay (thank goodness). Weekend footy is something I always look forward to though.

Pardon my asking, but you mentioned something about already looking for Step 2CK books, are you an IMG?

 

[Big Baller]

If the wife says to the physician what her husband said to her or in other words she says this what this what was instructed to me then wife's view would be used but if she says that she thinks that this is what my husband wants then living will would be used because she is saying what she thinks would be best but not what husband said. I know this is very subtle but I have got enough questions wrong and I have learned from my mistakes.
As someone earlier pointed that you would go with wife because its more recent is the right answer but the wrong reason. Time isn't an issue, its what husband instructed that matters.

 

[Phloston]

So is this correct?

1) DPOA
2) next of kin (patient's recent wishes expressed through him or her)
3) living will
4) next of kin (opinion)
5) POA (not durable)

 

[Big Baller]

So is this correct?

1) DPOA
2) next of kin (patient's recent wishes expressed through him or her)
3) living will
4) next of kin (opinion)
5) POA (not durable)

Its hard to rank them without looking at the vignette but this is hoe how I would rate it:
-If the patient is conscious and competent=Ask him
-If the patient is unconscious, left something is writing, didn't tell anything to anyone in the family and the family is not unanimous on what to do=Follow what is stated in the document that is left by the patient
-If the patient is unconscious, left something but also later told specifically something different or opposite to a family member=Follow what the family member says only if the question say that the family informs the physician in patients words or states what the patient said
-If nothing left in writing and family is fighting=encourage discussion among family members

 

[Big Baller]

So is this correct?

1) DPOA
2) next of kin (patient's recent wishes expressed through him or her)
3) living will
4) next of kin (opinion)
5) POA (not durable)

This is what works for me and hopefully help you out too.