Neurology Ethics (MedicalBooksVN - Com)

Item: 1 of 4 ~ 1 • Mark -<] C> Jill ~· ~J
QID: 22581 ..1 Previous Next Lab'V!I!ues Notes Calculator
• 1
A 20-year-old college student is brought to the emergency department (ED) after she was hit on the head by a stray ~~ A I
baseball. The patient was conscious when the first responders arrived at the scene, but she began complaining of a severe
headache and then lost consciousness en route to the hospital. Init ial CT scan shows a large epidural hematoma that
•4 requ ires emergent evacuation . The patient has not regained consciousness, and the ED clerk has not yet found her emergency
contact information .
Which of the following is the most appropriate next step in management?
A. Ask the patient's dormitory housemaster to sign a consent form for emergency treatment
B. Infuse mannitol to decrease intracranial pressure wh ile wait ing for the patient's parents to arrive
C. Perform emergent evacuation of epidural hematoma

D. Perform serial neurologic examinations while wait i ng for the clerk to obtain the information about the patient's
emergency contact
E. Wait for the parents to arrive before proceeding w ith any treatment
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•2
•3
The correct answer is C. 940/o chose this .
•4
Emergency treatments in life-threatening situations do not require consent; consent is implied . Therefore the most
appropriate next step is to perform emergency evacuation of the hematoma before further neurologic deficits develop. Should
all relevant parties be present, consent authority would serially fall upon (1) the patient's spouse; (2) an adult child of the
patient who has the waiver and consent of all other qualified adult children of the patient to act as the sole decision maker;
(3) a majority of the patient's reasonably available ad ult children; (4) the patient's parents; or (5) the ind iv idual clearly
identified to act for the patient before the patient became incapacitated, the patient's nea rest living r elative, or a member of
the clergy.
Hematoma Neurology
A is not correct. 2% chose this.

In the case of a life-th reatening condition, consent to t reatment is implied.
B is not correct. 30/o chose this.
While medica l management to decrease intracranial pressure may be appropriate in other types of intracrania l hemorrhage, a
progressing epidura l hematoma must be su rgica lly evacuated to relieve the pressu re.
Intracranial hemorrhage Epidural hematoma Intracranial pressure Hematoma Epidural administration Bleeding
Dis not correct. 1% chose this.

Serial neurologic examinations are appropriate for conscious patients while wait ing for a neurosu rgery consult, but the patient
in the case was already unconscious, and the operation must be performed immediately.
Neurosurgery Neurology
E is not correct. OOfo chose this.

Consent to treatment is implied when emergency treatment for a life-threaten ing condition is requ ired . Th is applies whether
or not the patient is a minor.
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1
In the case of a life-th reatening condition, consent to treatment is implied .
•2
B is not correct. 30/o chose this .
•3
While medical management to decrease intracranial pressure may be appropriate in other types of intracrania l hemorrhage, a
•4 progressing epidural hematoma must be surgically evacuated to relieve the pressure .
Intracranial hemorrhage Epidural hematoma Intracranial pressure Hematoma Epidural administration Bleeding
Dis not correct. 1% chose this.

Serial neurologic examinations are appropriate for conscious patients while wa iting for a neurosurgery consult, but the patient
in the case was already unconscious, and the operation must be performed immediately.
Neurosurgery Neurology
E is not correct. OOfo chose this.

Consent to treatment is implied when emergency treatment for a life-threatening condition is required. This applies whether
or not the patient is a minor.
Bottom line:
Emergency treatments in life-threatening situations do not require consent; consent is implied . When consent is required for
a procedure in the non-emergent setting on a patient who is incapable of providing consent for him/herself, the authority of
providing consent falls on ( 1) the patient's spouse; (2) .an adult child of the patient; ( 3) a majority of the patient's
reasonably available adult children; (4) the patient's parents; or (5) the ind ividua l clea rly identified to act for the patient
before the patient became incapacitated, the patient's nearest living relative, or a member of the clergy.
Clergy
References:
FA Step 2 CK 9th ed p 126
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1
An 82-year-old man is in the medical intensive care unit following a suicide attempt that has left him without higher
•2
cortical functioning. A neurologist has determined that the patient is in a persistent vegetative state, with little chance of
•3 recovery to his previous state, although he is medically stable . His wife is deceased, and his son, with whom the patient
•4 was close, is currently unreachable. His closest family who is present is his nephew, w ith whom the patient has not had contact
for many years. The patient has no advance directive, and the nephew does not recall any discussions with the patient
indicating his desires for end-of- life care. The nephew believes that in the absence of the patient's son, artificial nutrition and
hydration shou ld be withdrawn because there is little hope for recovery.
Which of the following is the best course of action?
A. Continue artificial hydration and nutrit ion because withdrawal wou ld be illegal
B. Defer any decision until the patient's son can be contacted
C. Follow the nephew's decision because he is the closest kin available
D. Use substituted judgment to make a decision for the family
E. Withd raw care by reasoning of medical futility
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The correct answer is B. 600/o chose this.
2
In any end-of-life decision, every attempt should be made to include individuals who know the patient well and could be
•3 relied on for substituted judgment. These individuals may not necessa rily be family members, so even friends or other
•4 acquaintances may be consider ed if they have a close r elationship with the patient. I n this case, the son is most likely to
know the patient's desires for end-of-life care and, if possible, should be the primary decision maker.
End-of-life care End-of-life (product)
A is not correct. 8% chose this.

The U.S. Supreme Court decision in the Cruzan case established that competent patients have a constitutionally protected
right to refuse any unwanted treatment. Additionally, artificia l nutrit ion and hydration were treated as equivalent to any other
medical treatment and thus could be refused li ke any other treatment.
Supreme Court of the United States Feeding tube
C is not correct. 120/o chose this.

The nephew has not been in touch with the patient for many yea rs, and it is unclear on what grounds he is making the
decision to withdraw nutrit iona l support. The physician shou ld always consider any possible conflicts of interest that may
adversely influence the decision making.
Conflict of interest Physician
D is not correct. 8% chose this.

Making a decision for the family would not be appropriate, particularly because the possibility remains that the son may
become available to provide the most reliable substituted judgment.
E is not correct. 12% chose this.
Medical futility may be invoked in cases in which treatment wou ld not achieve the desired outcome for the patient. However,
it is not appropriate to make this decision w ithout consulting the family first.
Futile medical care
I Bottom line:
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1 right to refuse any unwanted treatment. Add it ionally, artificial nutrition and hyd ration were treated as equivalent to any other
2 medical t reatment and thus could be refused like any other treatment.
Supreme Court of the United States Feeding tube
•3
•4 C is not corre ct. 1 20/o chose this .
The nephew has not been in touch with the patient for many years, and it is unclear on what grounds he is making the
decision to withdraw nutritional support. The physician should always consider any possible conflicts of interest that may
adversely influence the decision making.
Conflict of interest Physidan
D is not correct. 8 % chose this.

Making a decision for the family would not be appropriate, particularly because the possibility remains that the son may
become available to provide the most reliable substituted j udgment.
E is not correct. 12% chos e this .
Medical futility may be invoked in cases in which treatment would not achieve the desired outcome for the patient. However,
it is not appropriate to make this decision w ithout consulting the family first.
Futile medical care
Bottom line :
In any end-of- life decision, every attempt should be made to include ind ividua ls who know the patient well and could be
relied on for substituted j udgment.
End-of-life (product) End-of-life care
References:
FA Step 2 CK 8th ed pp 115-116
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After a sailing accident in which a 27-year-old man falls overboard, he arrives at the emergency department with a
2 temperature of 25°C (77.0°F), no spontaneous respirations or cardiac activity, and a depressed skull fracture. Rewarming
•3 is begun, the man is intubated and mechanically ventilated, and cardiotropic medications are administered, result ing in a
•4 faint, palpable, pulse. The "doll's-eyes" reflex is absent. There is no deviation of the eyes in response to irrigation of the ear
canal with ice water. His Glasgow Coma Scale score is 3/15 . Body tem perature after CT is 28.1°C (82 .5°F). The family asks the
treating doctor about his prognosis.
Which of the following patient characteristics must be corrected before evaluating for brain death?
A. Body temperature
B. Cardiac activity
C. Glasgow Coma Scale score of 3
D. Skull fracture
E. Spontaneous respirations
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•4 The correct answer is A. 660/o chose this.
Before a diagnosis of bra in death can be made, there are certain potentially con founding cond itions that must be corrected .
One is a core body temperature <36°C. Lower temperatures exhibit a neuroprotective effect via enzyme inhibition, and
patients have been successfu lly resuscitated with neu rologic recovery even after long periods of cardiac arre st if the patient's
core body temperature was low at the time of arrest. Warming blankets can be used to raise the patient's core temperature .
The other condition that must be corrected is a normal systolic blood pressure of < 100 mm Hg. Other prerequisites include
evidence of a catastrophic cerebral event, the absence o1f intoxication or poisoning, and the absence of metabolic or endocrine
derangements.
Brain death Enzyme Blood pressure Enzyme inhibitor Neuroprotection Cardiac arrest Endocrine system Human brain Thermoregulation Brain Neurology Metabolism Systole

Historically, cardiac arrest was used to define death . Now, however, death is defined by brai n death. Presence or absence of a
heartbeat is not part of the evaluation for bra in death .
Brain death Cardiac arrest Human brain Brain Heart rate
C is not correct. 7% chose this.

As one point for each category defines the bottom of the Glasgow Coma Scale (GCS), a 3 is the lowest possible score . A
patient scoring 3 of 15 is profoundly comatose, and coma and/or absence of cerebral motor responses is one of the diagnostic
criteria for brain death . A GCS score of 3 does not need to be corrected before evaluation for brain death can procee d.
Glasgow Coma Scale Brain death Coma Brain Glasgow Human brain

Evidence of a devastating neurologic event is one of the ,criteria that must be met before evaluation for brain death can
proceed; the presence of a skull fracture is consistent wit h such an event, and would not hinder the evaluation for brain death
in this patient.
Brain death Skull fracture Human brain Neurology Human skull Skull Bone fracture Brain
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1
C is not correct. 70/o chose this.
2
As one point for each category defines the bottom of the Glasgow Coma Sca le (GCS), a 3 is the lowest possible score . A
3 patient scoring 3 of 15 is profoundly comatose, and coma and/or absence of cerebral motor responses is one of the diagnostic
•4 criteria for brain death . A GCS score of 3 does not need to be corrected before evaluation for brain death can proceed .
Glasgow Coma Scale Brain death Coma Brain Glasgow Human brain

Evidence of a devastating neurologic event is one of the ,c riteria that must be met before evaluation for brain death can
proceed; the presence of a skull fracture is consistent wit h such an event, and would not hinder the eva luation for brain death
in this patient.
Brain death Skull fracture Human brain Neurology Human skull Skull Bone fracture Brain
E is not correct. 11% chose this.

The absence of spontaneous respirations in this patient is part of the evaluation for the diagnosis of brain death . Apnea of
more than 8 minutes with PC0 2 > 60 mm Hg is one of t he diagnostic criteria for brain death . This is incorrect because
respiratory status does not need to be corrected before evaluating for brain death . (Of course, ventilation would be addressed
appropriately during resuscitation efforts.)
Brain death Apnea Ventilation (physiology) Human brain Brain Cardiopulmonary resuscitation Resuscitation
Bottom line:
A diagnosis of brain death requires a core body temperature of at least 34°C.
Brain death Thermoregulation Human brain Brain
References:
FA Step 2 CK 9th ed pp 128; 126
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A 75-year-old cognitively intact woman with a history of dia betes, coronary artery disease, hypercholesterolemia, and
2 peripheral vascular disease is admitted for dehydration caused by frequent bouts of vomiting over the past 5 days. The
3 patient also has a 2-month history of headaches, which are worse in the morning. Physica l exam ination shows bilateral
•4 papilledema but no focal neurologic abnormal ities . An MRI scan is highly suggestive of gl ioblastoma multiforme. On entering the
room to inform t he patient of her likely diagnosis and discuss the next possible steps in management, the patient exclaims
"Doctor, I 'm so tired of suffering . I don't want to know what I have, I just want you to make me feel better."
Which of the following is the best way to approach th is issue with the patient?
A. Discuss the case with the hospital's eth ics committee to determine the next appropriate step in the patient's ca re
B. Inform the patient of her diagnosis, because this disease is incredibly serious and life-threaten ing
C. Inform the patient's relatives of her diagnosis so that they can convince the patient to have a surg ica l resection
D. Obtain a psychiatric consult to determine the patient's decision-making capabilities
E. Ta lk with the patient about her fears concerning her condition
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Like Dislike
2
3
The correct answer is E. 91% chose this.
4
Although competent patients have the righ t to r efuse information, it is important to determine why the patient does not want
to know her diagnosis and what fears may be driving her decision .
A is not correct. 1 Ofo chose this.
Although sometimes it may be necessary to discuss difficult cases with the ethics comm ittee, it is im portant for the physician
to f irst talk w ith the patient to determ ine why he or she wants you to withhold information .
Ethics Physician

A patient has the right to refuse information . When a patient makes such a r equest, it is important to understand why the
patient does not wan t the information .
C is not correct. 1 Ofo chose this.
In almost all cir cumstances, information about a patient's medical condition is confidentia l and cannot be divulged w ithout the
expressed patient consent, regardless of disease severity. Some instances in which there is an ethical and legal necessity to
override confidentia lity are as follows: patient intent on comm itting a violent crime; suicida l patients; child and elder abuse;
infectious diseases (duty to warn public officials and identify people at risk); and gunshot and kn ife wounds (duty to notify
police) .
Elder abuse Duty to warn Confidentiality

In th is case, the patient is cognitively intact and gives no indication that she lacks decision-making capacity. For a doctor
whose patient refuses information, it is important to talk w ith the patient to understand why the patient wants you to
w ithhold information and to gauge the patient's decision-making capacity.
Rnttnrn I in~·
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• e I I I - - • 'f I- - - • 'f e I I I I • - ' ' "' - I -"' I I • I - I " •
1
to first t alk with the patient to determine why he or she wants you to withhold information .
2 Ethics Physician
3
B is not correct. 4 0/o chose this .
4
A patient has the right to refuse information . When a patient makes such a request, it is important to understand why the
patient does not want the information .
C is not correct. 1 0/o chos e this .
In almost all circumstances, information about a patient's med ical condition is confidential and cannot be divulged w ithout the
expressed patient consent, regard less of disease severity. Some instances in which there is an ethical and legal necessity to
override confidentiality are as follows: patient intent on committing a violent crime; suicidal patients; ch ild and elder abuse;
infectious diseases (duty to warn public officials and identify people at risk); and gunshot and knife wounds (duty to notify
police) .
Elder abuse Duty to warn Confidentiality
D is not correct. 3% chos e this .

In this case, the patient is cognitively intact and gives no indication that she lacks decision-making capacity. For a doctor
whose patient refuses information, it is important to talk with the patient to understand why the patient wants you to
w ithhold information and to gauge the patient's decision- making capacity.
Bottom line :
Although competent patients have the right to refuse information, it is important to determ ine why the patient is declining
disclosure of the information and what fears may be driving that decision .
References:
FA Step 2 CK 8th ed pp 116-117
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A 75-year-old cognitively intact woman with a history of diabetes, coronary artery disease, hypercholesterolemia, and
2 peripheral vascular disease is admitted for dehydration caused by frequent bouts of vomiting over the past 5 days. The
3 patient also has a 2-month history of headaches, which are worse in the morning. Physica l exam ination shows bilateral
4 papilledema but no focal neurologic abnormalities . An MRI scan is highly suggestive of gl ioblastoma multiforme. On entering the
room to inform the patient of her likely diagnosis and discuss the next possible steps in management, the patient exclaims
"Doctor, I 'm so tired of suffering . I don't want to know what I have, I just want you to make me feel better."
Which of the following is the best way to approach th is issue with the patient?
• A. Discuss the case with the hospital's eth ics committee to determine the next appropriate step in the patient's care
B. Inform the patient of her diagnosis, because this disease is incredibly serious and life-threaten ing
C. Inform the patient's relatives of her diagnosis so that they can convince the patient to have a surg ica l resection
D. Obtain a psychiatric consult to determine the patient's decision-making capabilities
E. Ta lk with the patient about her fears concerning her condition
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Item: 1 of 4 ~ 1 • Mark -<] C> Jill ~· ~J

QID: 22581 ..1 Previous Next Lab'V!I!ues Notes Calculator

Which of the following is the most appropriate next step in management?

C. Perform emergent evacuation of epidural hematoma

A is not correct. 2% chose this.

Dis not correct. 1% chose this.

E is not correct. OOfo chose this.

Dis not correct. 1% chose this.

E is not correct. OOfo chose this.

Which of the following is the best course of action?

B. Defer any decision until the patient's son can be contacted

C. Follow the nephew's decision because he is the closest kin available

D. Use substituted judgment to make a decision for the family

E. Withd raw care by reasoning of medical futility

A is not correct. 8% chose this.

C is not correct. 120/o chose this.

D is not correct. 8% chose this.

D is not correct. 8 % chose this.

B is not correct. 100/o chose this.

C is not correct. 7% chose this.

D is not correct. 6% chose this.

D is not correct. 6% chose this.

E is not correct. 11% chose this.

D. Obtain a psychiatric consult to determine the patient's decision-making capabilities

E. Ta lk with the patient about her fears concerning her condition

B is not correct. 40/o chose this.

D is not correct. 3% chose this.

D is not correct. 3% chos e this .

D. Obtain a psychiatric consult to determine the patient's decision-making capabilities

E. Ta lk with the patient about her fears concerning her condition

SHOW All EXPLANATIONS

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