Which Patient Receives the Treatment?

Started by dxcrunner
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dxcrunner

dxcrunner

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What is a clever way to respond to a question like:

"You have one dialysis machine to share between three patients with equal medical need. One is a 17-year-old drug addict who has just overdosed, one is a 40-year old woman with terminal breast cancer and only 6 months of life expectancy, the third one is a 70-year old marathon runner. Who gets the machine?"
 
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dxcrunner said:
What is a clever way to respond to a question like:

"You have one dialysis machine to share between three patients with equal medical need. One is a 17-year-old drug addict who has just overdosed, one is a 40-year old woman with terminal breast cancer and only 6 months of life expectancy, the third one is a 70-year old marathon runner. Who gets the machine?"
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Personally, i'll choose the breast cancer one due to a personal bias and tie that to my story. But the conventional answer is first come first serve.

The drug addict is the issue of noncompliance.
 
They get to take turns. Dialysis only takes 2-4 hours. Breast cancer patient first, marathon runner second, drug addict third. Unless drug addict is causing a ruckus for the nurses because they are tripping...then get that patient taken care of first.

I'd switch the question to a CRRT machine to make it interesting.
 
If they all came at the same time, 17 years old. Most likely to respond well to dialysis due to the age. We don't judge people's background.
 
LMBLBM said:
If they all came at the same time, 17 years old. Most likely to respond well to dialysis due to the age. We don't judge people's background.
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Wait are we taking this question seriously?

Also, not sure how well a 17 year old requiring dialysis due to kidney damage caused by drugs will respond to treatment. I haven't seen good outcomes with the handful of young patients that are sick enough (for that reason) requiring dialysis.
 
2Pints said:
Wait are we taking this question seriously?
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Because many schools now use MMI format for their interviews and sometimes ask very difficult questions such as this one. It's good to at least think about how you would answer some ethical dilemma questions before you go.
 
To answer the question my response would be something like this. "Wow what a difficult question! I'm not a kidney specialist, so I would want to speak with one to determine which of these three patients would be helped the best from dialysis. If I can't speak to a specialist, I would give the machine to the 17 year old as he might have the opportunity to have the greatest long-term benefit. I would also see if I could have a social worker give him some counseling/refer him to resources that might help him overcome his drug addiction."
 
accueil said:
Because many schools now use MMI format for their interviews and sometimes ask very difficult questions such as this one. It's good to at least think about how you would answer some ethical dilemma questions before you go.
Click to expand...
The "clever way to respond" threw me off. Do we have to stick to the parameters of the given dilemma? For instance, I would get environmental or get in contact with a dialysis nurse to find another machine. There's no way there can only be one available for three sick patients. Routine dialysis on stable patients can be stopped so those machines are better distributed. Also, does the terminally ill breast cancer patient have any sort of advanced directive? Have we had a conversation with this patient about how aggressive we want to get in treatment? And saying same medical need just doesn't seem like enough information. Will all three patients die if they don't get dialysis or can they wait?
 
Because many schools now use MMI format for their interviews and sometimes ask very difficult questions such as this one. It's good to at least think about how you would answer some ethical dilemma questions before you go.
Click to expand...
What was the "old" method of asking questions if this is considered a new method to ask ethical questions? I have been been tearing through lists of interview questions to be ready for anything.

For some reason it didn't quote the message and had to insert it manually...
 
dxcrunner said:
What was the "old" method of asking questions if this is considered a new method to ask ethical questions? I have been been tearing through lists of interview questions to be ready for anything.
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You're totally right that traditional interviews can also have questions like this one. I have just been under the impression that at an MMI school you will definitely have a series of questions like this (i.e. you see the question and have a minute to think of your response, go into the room and deliver your response).
 
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accueil said:
You're totally right that traditional interviews can also have questions like this one. I have just been under the impression that at an MMI school you will definitely have a series of questions like this (i.e. you see the question and have a minute to think of your response, go into the room and deliver your response).
Click to expand...

I just looked at a list of all the MMI schools, and I didn't apply to any of them anyway. I never knew they existed before you mentioned it.
 
Psai said:
Hook them all up together like the human centipede
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how about a human kidneypede 😛? authorize the creation of one giant master kidney that is attached to all of three of them and runs through all three of their bodies exteriorly and hook up the dialysis machine to it.
 
2Pints said:
Wait are we taking this question seriously?

Also, not sure how well a 17 year old requiring dialysis due to kidney damage caused by drugs will respond to treatment. I haven't seen good outcomes with the handful of young patients that are sick enough (for that reason) requiring dialysis.
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Oh I thought drug overdose and dialysis requirement were independent
 
LMBLBM said:
Oh I thought drug overdose and dialysis requirement were independent
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They could unrelated. Since drugs are either metabolized by the kidney or liver a drug addict can do damage to either organ. The former potentially leading to kidney failure. There's also the possibility the patient could have picked up infective endocarditis from dirty needles. Then the patient becomes septic and goes into multiple organ failure. That I have seen. It was a horrible way to die.
 
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There's no clever answer to this type of question. Just weighing the pros and cons of different approaches. I would say you treat whoever walks in the door first. It's not a doctors job to pass judgement on people.
 
phunky said:
It's not a doctors job to pass judgement on people.
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Ah but unfortunately it sometimes is. First person who needs dire treatment is not necessarily the one who "should" receive it when resources are limited. For example, trauma centers with transplant programs have a committee of physicians that answers questions very similar to this and determine which patient should get the limited resource.

So if you served on the committee what would be your answer?

(I'm interested to know. But more generally, be prepared for pushback/follow up questions to your ethical dilemma answers similar to this)
 
There isn't enough info on the breast cancer patient or marathon runner to determine how urgently or even if they need dialysis. It says the 17 year old just overdosed and if it's the drugs causing impacting kidney function. The other two can take turns based on clinical picture of urgency.
 
(IMHO) Medical school interviews are not going to assume that you know the intricacies of hospital policy or dialysis best practices. That is not to say you can't bring your knowledge of random things like Door-to-balloon time project implementation to the table. However, I think you'd be hard pressed to find a MMI interviewer expecting you to use ejection fraction in your reasoning for an ICD.

It's a test of your ability to critically think through a scenario and to analyze it from different perspectives. It tests whether or not you can see the ethical reasoning behind each choice, not necessarily whether you come up with THE right answer. On some level, it probably screens for some sketchy personality types too.

Answer shouldn't look like this: "The grandmother because she's taken charge of her health and not the terminal patient. The drug-addicted kid is aware of his health choices so he gets last priority."
 
Doctor Strange said:
I was being sarcastic. "Consult the ethics committee" is notoriously never the answer to an ethics question on boards.
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I'd probably be safe assuming 95% of the posts that sound ridiculous are sarcastic. If only there were away to convey a sarcastic tone without emoticons.
 
The rationale behind the question is that once upon a time, there literally was not enough dialysis equipment (more accurately enough money/funding) to go around. There were panels that had to determine who got dialysis, and this was a feature article in Life Magazine in the 60s on it (called "god committees").

So I would hardly recommend going "hurr durr I'd give them all dialysis on one machine - it doesn't take all day!".

The point of the question is to get you to think about the moral/societal underpinnings of rationed care.
 
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I'd say that whoever walked in first should get treatment. If they all walked in at the same time, then I'd say the 17 year old Because that person would have the longest time to benefit from the machine a well as the 17 year old being the most urgent patient. Would it be wise to avoid the ethical dilemma and go straight to quasi-quantifiable measures. Or are they looking for an answer that corresponds to the ethics of deciding?
 
LizzyM has a great point. these scenarios are really vague. in real life each person has a lot more of them than being a "drug addict", "cancer survivor", or "old marathon runner".
 
I'd probably choose the OD'ed 17yo, considering the life-year benefit and all that. There is no easy answer, and the interviewers aren't looking for the "right" answer, but rather a rational and thought out explanation as to why you chose the way you did.
 
I feel like these questions largely serve to see how black-and-white your thinking is.

The first sentence says "share"...so why aren't we sharing? Hemodialysis machines are shared amongst patients, and continuous ambulatory peritoneal dialysis doesn't require a machine.

If I had to "pick" someone to use the machine, it would be the 17 year old. Drug overdose is an acute condition, and hemodialysis is used for acute kidney failure. From the information given, I'm assuming the other two patients have chronic kidney failure, and even if they all have "equal medical need" for treatment, there isn't a given reason why it would be needed immediately, and they have options such as peritoneal dialysis and kidney transplants.

The doctor should talk to the terminal patient about her wishes. She has a limited amount of time left and has the right to decide if she wants to spend that time doing dialysis. If she does, she would most likely benefit more from peritoneal dialysis, which tends to be a little "easier" on the patient's body as well as having a better survival rate than hemodialysis for the first 2 years of treatment, which would increase her chances of living for the full six months.

I also think the marathon runner would benefit more from peritoneal dialysis for similar reasons, and continuous ambulatory dialysis would allow him or her to stay somewhat active compared to hemodialysis. This patient is also the one with the highest chances of qualify for a cadaver kidney.
 
Did you come up with this scenario or did you find it somewhere? I can understand asking about a kidney or liver or some other organ transplant, but a dialysis machine? It doesn't take that long to run a dialysis, so all 3 could use the machine in the same day. If you need to pick an order, 17 y/o first, as she is in the most acute situation. They don't give any info about the renal status of the woman or the marathon runner, but most likely they can wait a few more hours. If they want to pick a machine for the scenario instead of the classic organ transplant, at least pick an ECMO or something. THAT'S a bigger dilemma.

Doctor Strange said:
Consult the ethics committee.
Click to expand...

In actuality, probably. For board question purposes, nope.
 
How about responding with an answer from your own heart, instead of mining SDN for potential answers?

Hint, there's no correct answer for this one.

dxcrunner said:
What is a clever way to respond to a question like:

"You have one dialysis machine to share between three patients with equal medical need. One is a 17-year-old drug addict who has just overdosed, one is a 40-year old woman with terminal breast cancer and only 6 months of life expectancy, the third one is a 70-year old marathon runner. Who gets the machine?"
Click to expand...
 
LizzyM said:
Do they ever change up the scenarios?.... the drug addict is a TV star and/ or the son of a US senator... the 70 year old marathon runner is also a registered nurse who still works part-time, the cancer patient has a wing of the hospital named for herself and her husband.
Click to expand...

That's a better scenario which will be fun to answer. I'll stick with my previous one and spin it to my favor. There really isn't a right answer and i doubt adcoms are expecting applicants to know different type of dialyses and how they work.
 
2Pints said:
They get to take turns. Dialysis only takes 2-4 hours. Breast cancer patient first, marathon runner second, drug addict third. Unless drug addict is causing a ruckus for the nurses because they are tripping...then get that patient taken care of first.

I'd switch the question to a CRRT machine to make it interesting.
Click to expand...

And if the interviewer won't let you take turns, then you temporize the pts as best as possible, call other hospitals to arrange transfer, and treat the one you're keeping.

If the interviewer doesn't accept that either, just say, "Well, now you're being intentionally ridiculous. Is this the type of ridiculousness I should expect in the medical education at this institution?" Or to make it open ended, "In what ways has your medical school chosen to incorporate ridiculous scenarios into the curriculum?"
 
TooMuchResearch said:
And if the interviewer won't let you take turns, then you temporize the pts as best as possible, call other hospitals to arrange transfer, and treat the one you're keeping.

If the interviewer doesn't accept that either, just say, "Well, now you're being intentionally ridiculous. Is this the type of ridiculousness I should expect in the medical education at this institution?" Or to make it open ended, "In what ways has your medical school chosen to incorporate ridiculous scenarios into the curriculum?"
Click to expand...

I hope I'm not in a snarky mood if I get asked this question. Because after my work day today your response doesn't sound nearly as ridiculous as the question. 🙂
 
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