Sep 5, 2016
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In preparing for interviews, I feel less confident about the scenario type of questions. Any advice on how to approach something like the sample question below? I have ideas on how to answer, I guess I just get nervous that I might say something totally wrong (in terms of professional medical decision making).

A patient who has been in an accident needs a blood transfusion. She states that her religion does not allow them. You are the physician in charge. What will you do? Will you override her strong objection? Why/why not?

My gut tells me that I should respect the patient's wishes. Am I left to only try to find alternative treatments that she wouldn't object to?
 

MDProspect

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https://depts.washington.edu/bioethx/toc.html
http://forums.studentdoctor.net/threads/pugs-mmi-interview-strategy.1183568/
Both of these links will help you formulate your responses.

Without providing any supporting evidence or a thought process, your answer might come off as an extreme.
Although I do agree with your "gut feeling", I would tell the interviewer that I would first want to know the age of the patient and whether she is competent. If she is a minor, this complicates the decision. The parents' wishes may differ from the patient's wishes. Usually the parents' authority supersedes the minor's. Thus, if the parents are available, you should consult with them and respect their wishes. If not, you should be inclined to save the patient's life over siding with her religious beliefs. Yes, it goes against the patient's autonomy, but the minor's rights are limited. There have been cases where the physician respected the minor's wishes and went against the parents, but there is not a precedent on how you should act and you should not follow these cases without consulting with your peers and the hospital's ethics committee. Competence, on the other hand, should dictate on how you will proceed. The accident may have rendered the patient's judgement and this is not what she would want under normal conditions. Furthermore, she might be chronically incompetent (i.e she has a mental illness). I would assume that unless she has a parent, spouse or a friend with her, then you don't have enough time to go out and explore what are the patient's normal wishes. With the limited time, I would check the hospital's registry to see if the patient has been to the hospital before. This will allow me to get to know more about her and make an evidence-based decision. Secondly, a cognitive test should be done. This will help you decide whether these are the true wishes of the patient. If you have any suspicions, I would say to save her life (perform the transfusion). If your patient is a competent adult, then you should respect her autonomy. Not saving her life seems like a contradiction to the "do no harm", but you are still harming the patient by not respecting her authority and wish.

Edit: I forgot to mention that you should also explain the risks of not performing the blood transfusion. The patient might not understand the seriousness of her situation.

Hence you should:
1) Determine the age and mental state of the patient.
2) Explain the risks and act accordingly.
 
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WheezyBaby

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Nitpicking, but physicians determine capacity, not competency.

I know this isn't what you said, but fwiw, mental illness, even schizophrenia, does not necessarily mean lack of capacity. As far as kids, if a kid emergently needs blood, they get blood; parents don't get a say.
 

MDProspect

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Nitpicking, but physicians determine capacity, not competency.

I know this isn't what you said, but fwiw, mental illness, even schizophrenia, does not necessarily mean lack of capacity. As far as kids, if a kid emergently needs blood, they get blood; parents don't get a say.
I used "competence" as it used by the Uni of Washington's ethical guideline. Yeah, I agree that a mental illness does not necessarily mean that a patient is incapacitated as they can be lucid and coherent during the encounter; however, should not it make you cautious about the patient's current mental condition? In Doing Right by Dr. Hebert, he mentions a case where a 14 year old Jehovah's Witness was not given a blood transfusion. His doctors determined that he was not being influenced by his parents and his mental capacity was beyond his normal age, thus his wishes were respected. Another interesting case that he mentions is about an anorexic minor who was not forced fed and was allowed to die even though the parents were for force feeding. Would it not be more proper to evaluate your patient and then act accordingly than thinking that you have a carte blanche to do procedures that your patients don't want?
 

WheezyBaby

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  • I used "competence" as it used by the Uni of Washington's ethical guideline. Yeah, I agree that a mental illness does not necessarily mean that a patient is incapacitated as they can be lucid and coherent during the encounter; however, should not it make you cautious about the patient's current mental condition? In Doing Right by Dr. Hebert, he mentions a case where a 14 year old Jehovah's Witness was not given a blood transfusion. His doctors determined that he was not being influenced by his parents and his mental capacity was beyond his normal age, thus his wishes were respected. Another interesting case that he mentions is about an anorexic minor who was not forced fed and was allowed to die even though the parents were for force feeding. Would it not be more proper to evaluate your patient and then act accordingly than thinking that you have a carte blanche to do procedures that your patients don't want?

If there's clear benefit of and need for emergent treatment, there's very little likelihood I'm going to factor in a minor's opinion, particularly in a situation like a jehovah where there's a strong possibility for an element of coercion. It'd be an ethics consult at least, and if there isn't time there isn't time. With regard to anorexia, the concept of futile care for chronic mental illness is not well characterized in adults, certainly not for kids. I can't fathom withdrawing forced feeds in that situation when it's a decision for a minor with a mental illness where the decision is directly determined by their disturbed perception of self AND the parents aren't on board with the decision. With regard to the last statement, really? For nonemergent situations where mental illness doesn't play a direct role, sure, evaluate capacity