ETHICS

Question 1: Allegations of negligence A 50-year-old woman had an elective cholecystectomy. She experienced complications and was frustrated by the lack of information given to her by the surgeon after the surgery. She launched a legal action. What principle of law was the claim likely based on? Choose the best answer: A) B) C) D) E) Breach of fiduciary duty in the doctor-patient relationship Failure to provide value for the taxes she paid into the health care system Negligence or civil liability (fault) related to the performance of the surgery Breach of contract Assault and battery related to the failure to obtain informed consent

Question 2: Negligence and the role of medical experts Despite appropriate monitoring of gentamicin levels, a patient with sepsis suffered renal damage, perhaps partially as a result of the medication. A lawsuit alleging negligence or civil liability (fault) was launched, claiming the renal damage was preventable. What will the court consider related to the standard of care? Choose the best answer: A) B) C) D) The court will determine the standard based on excellence or perfection in medical care The court will determine the standard based completely on existing pharmacology textbooks available at the time the care was provided The court will determine the standard based completely on existing published guidelines for the administration of gentamicin The court will generally determine that poor outcomes are the result of negligent or below standard care The court will determine the standard based on what experts testify about the care and skill that could reasonably be expected of a physician with similar training and working in similar circumstances

E)

. as an infection would likely have resulted anyway. contributed to this event System process changes are unlikely to lessen the probability of a reoccurrence of this event for other patients Provider performance failure resulted in this event and discipline of all those involved is usually the best way to prevent reoccurrences The wrong dose of the medication is not important. A very high dose was given based on an inaccurate body weight.Question 3: Disclosure .Understanding harm A patient with leukemia correctly received a chemotherapeutic medication which resulted in neutropenia. Profound neutropenia resulted and the child acquired an infection. or both. choose the best answer: A) B) C) D) E) This event only resulted from a recognized inherent risk of using that chemotherapeutic agent System or provider performance failures. In considering the reasons for this adverse event. followed by an infection. Choose the best answer: A) B) C) D) E) A system change is the best way to prevent such problems The health professionals involved should apologize and admit responsibility in this circumstance Although this is an adverse event. not a system failure or provider performance issue Discussion with the patient of the level of white blood cell count and possible link to the infection is not helpful. it is an inherent risk of treatment. This is a recognized inherent risk of that medication and the possibility was discussed in the consent for treatment discussion. as consent was obtained The providers can assume the patient will not be surprised by the occurrence of a complication if it was discussed in the consent process Question 4: Disclosure – Understanding adverse events A seven-year-old child with leukemia was administered a chemotherapeutic agent known to cause neutropenia.

and the baby was healthy. Neither physician discussed the tear with the patient. Choose the best statement: A) B) C) D) The disclosure of adverse events to patients is considered a professional obligation by all Colleges in Canada Disclosure discussions are always led by the administration of a hospital/institution In many situations involving medical care. The problem was caught in time by chance. The patient was transferred back to her attending obstetrician for postnatal management. She had been pushing for nearly three hours and was tired. The patient complained to the provincial/territorial regulatory authority (College) about both the care and the communication. The resident almost performed the procedure on the wrong patient due to an inaccurate patient identification wrist band. which was also successfully managed. Choose the correct statement that applies: A) B) C) D) E) In Canada. The obstetrician on call advised the baby should be delivered by forceps.Question 5: Disclosure – Understanding close calls A staff physician assigned a PGY3 surgical resident* to perform a small surgical procedure. it is best if any disclosure is delayed until all the facts are in and understood Only critical incidents require discussion with the patient . a close call must always be discussed with the patient Close calls generally harm patients A patient should receive knowledge of a close call if there is an ongoing safety risk for that patient An event that does not result in harm is not worth reporting to the appropriate hospital authority. A fourth degree tear of the perineum required repair. as prevention is difficult Trainees involved do not need to report adverse events or close calls to their supervisors Question 6: The need for communication A young woman in her first pregnancy was failing to progress in the second stage of labour. The tear did not heal well and the patient needed further surgery. Forceps delivery of the head was followed by shoulder dystocia.

with labored respirations. The emergency physician considered immediate endotracheal intubation was necessary. but adequate blood pressure. On arrival at the hospital by ambulance. he was unresponsive. as the risks of general anesthesia are the most serious risks for this patient A consent discussion is not important as the patient has cancer and must have this surgery as an emergency The surgeon is responsible for all consent discussions The surgeon should discuss the risks related to the thyroidectomy and the anesthesiologist the risks of anesthesia The surgeon should have the consent discussion for the thyroidectomy. but because the risks of anesthesia are common knowledge. the anesthesiologist need not have a discussion with the patient E) Question 8: Consent in emergency situations A 57-year-old male collapsed while walking alone. What is the best next step? A) B) C) D) E) Await consent from an appropriate substitute decision maker before initiating airway management Attempt to call the family for advice before proceeding Treat immediately without consent. Who is responsible for the consent discussion with this patient? Choose the best answer: A) B) C) D) The anesthesiologist. as this is a life-threatening condition Delay invasive treatment until the patient is able to consent Seek an opinion from an ICU specialist before initiating treatment A .E) The hospital lawyer always should attend disclosure discussions related to serious adverse events Question 7: Responsibility for consent discussions A 57-year-old woman with carcinoma of the thyroid is booked for a thyroidectomy.

a consent discussion is not required Provide the patient with a pamphlet on the benefits and risks of carpel tunnel surgery as this precludes the need for a consent discussion Proceed without consent as this surgery is important to the patient’s income Question 10: Confidentiality. You have provided care to her entire family for many years. emotionally mature and mentally capable (competent) 15-year-old female attends your clinic seeking the oral contraceptive pill (OCP) for contraception. so that she can decide whether to proceed Ask her permission to call her parents to obtain their permission for contraception . privacy and consent of minors An unaccompanied. She has no contraindications. including consideration of the vocation of this patient Proceed without a consent discussion as this is a relatively short procedure with local anesthesia only. As the surgeon performing the procedure. What is the best next step? A) B) C) D) E) Call her parents to explain the situation and obtain their permission for contraception for their daughter Refuse outright to provide her with the OCP as she is too young to understand and consent Refuse outright to provide her with the OCP and admonish her for sexual activity at her age Provide or arrange sexual counseling. what is the next best step? A) B) C) D) E) Proceed if the patient lies down on the operating table because consent is implied Discuss the risks of surgery in detail. requiring carpel tunnel release.Question 9: Implied versus expressed consent A 44-year-old part-time street musician experiences persistent numbness of the palm and first three digits of the hand. including a discussion of the risks and benefits of the OCP and alternatives.

Question 11: Consent and medical trainee A patient has been diagnosed with appendicitis. What information should the physician provide to the patient before she leaves the office? Choose the best answer: A) B) C) D) E) Every risk and benefit of the steroid therapy A detailed explanation of the pathophysiology of the condition with the appropriate basic science diagrams and treatment algorithms Only the less serious side-effects of the steroid therapy Only information related to the possibility of loss of vision or stroke The symptoms and signs that would indicate either a complication in her condition or a side-effect of the medication . as care by residents is expected in teaching hospitals The surgeon has no obligation to inform this patient about the participation of the resident as he/she remains fully responsible for the resident’s actions The surgeon should communicate the participation of the resident to the patient only if the resident will be performing the surgery alone The surgeon would only need to inform the patient if he/she believed there would be additional risks incurred by having the resident assist Question 12: Informed discharge A 70-year-old female with presumptive giant cell (temporal) arteritis is started on corticosteroids pending urgent temporal artery biopsy. The surgeon decides to delegate certain aspects of the appendectomy to the senior resident on the service. What should the surgeon tell the patient? Choose the best answer: A) B) C) D) E) The patient must be informed of the participation of the trainee in the surgery The surgeon has no obligation to inform this patient about the participation of the resident.

” X-rays of both lower extremities reveal a new fracture and other healing fractures. The patient’s wife. what is your best next step? A) B) C) D) E) At this stage it is uncertain as to what has happened.” There is no Advance Directive. prognosis and patient’s wishes and then provide your recommendations on how to proceed Wait for the patient’s oncologist to be available to assume the care of the patient Question14:Confidentiality. “everything possible should be done.Question 13: Consent.” whereas the son states his father has recently told him “he wished to die. You initiate further resuscitation. In addition to providing clinical care for the fracture. translation and cultural sensitivity A 72-year-old Chinese speaking male arrives at hospital. hypotensive and with an endotracheal tube in place. so contacting the authorities is premature Report the patient to the child welfare authorities as soon as possible because of your suspicion of child abuse Ask for a social work investigation on an urgent basis to determine whether this family is at risk Do a work-up for the child to rule out metabolic/endocrine reasons for the fractures Wait and see if there are more injuries in the future as children of this age often fall and injure themselves while playing . clarify with the family the medical condition. The father denies the child has ever been injured. What is the best next step? Choose the best answer: A) B) C) D) E) The wife is now responsible for all medical decisions for her husband and you are required to do everything she says Stop all resuscitation until the patient’s wishes are clarified by speaking with the patient’s oncologist Call the hospital lawyer to obtain a court order to stop treatment While resuscitation continues. The family arrives and explains the patient has inoperable lung cancer with metastatic disease and suffers constant pain. states.privacy and mandatory reporting A father brings his four-year-old child to the office because the child is not weight bearing following a “fall from a swing. substitute decision makers. unconscious. with her elder son translating.

Which of the following best reflects better record keeping practice? A) B) C) There is no need to record if an interpreter was required for obtaining a history from a patient with a language barrier Patient identification need only be routinely found on the first page of a hospital medical record If pharmacologic treatment is indicated. but with the ethanol level blacked out or not included A polite refusal to provide any information about whether the patient is intoxicated Question 16: Maintenance of medical records A mother and child attend a hospital clinic because of concern the child’s rash may be the first sign of “something serious. the physician suspects the patient is intoxicated with ethanol. the doctor should always transcribe the reported values into the medical section of the record.Question 15: Confidentiality and privacy – the police A 25-year-old male is seen in an emergency department with multiple traumas after a car crash. The police arrive in the department and enquire whether the patient is intoxicated. What information can the physician give the police immediately? Choose the best answer: A) B) C) D) E) The ethanol level The physician’s suspicion that the patient is intoxicated A suggestion to obtain a warrant for a blood sample as the result will be “interesting” A copy of the medical record.” The following day. rather than simply noting that the vitals were reviewed Entries are made as soon as practically possible after the patient encounter D) E) . the child was diagnosed with meningitis. only new prescriptions need be recorded in the chart If vitals are recorded in the nursing section of a hospital medical record. Based on the clinical examination.

The attending physician ordered medications and general observation. A) B) C) D) E) Not all health care professionals had liability protection Neither the nurses nor the doctor did all they could reasonably have done to communicate well There were not enough nurses for the number of patients on the ward Prediction of suicide is unreliable and this situation could not have been avoided The hospital had inadequate policies . but offer a copy Provide a copy because the medical record is owned by the provincial payer anyway Provide the original medical record to comply with privacy legislation Refuse because the medical record is not available for viewing by patients with psychiatric diagnoses in most cases Question 18: Collaborative care An 18-year-old male was admitted to a psychiatric ward because of suicidal ideation. The patient was upset because this information was in his medical record and it might affect his eligibility for. life insurance. or the cost of.Question 17: Ownership of medical records Your patient attended your private office for a health exam for insurance reasons. You had treated the patient for depression in the past. They did not convey their concerns verbally to the oncoming shift of nurses or to the physician. While making rounds. the nurses observed the patient becoming increasingly agitated. What was the major problem in this case? Choose one answer. They documented this in the medical record. Overnight. What should you do? Choose the best answer: A) B) C) D) E) Provide the actual record because it is owned by the patient but kept with the physician Refuse to give the original because the medical record is owned by the physician. the physician did not read the nurse’s notes. The patient attempted to harm himself in his hospital room. He demanded his entire medical record so that he could take it away.

there should be no problem There is no concern because you are both consenting adults . One of your first patients has recently separated from a marriage. What should you be concerned about? Choose one answer: A) B) C) D) E) Your spouse may be suspected of drug seeking behaviour You have forged a prescription Your pharmacist acted improperly in making the complaint You may have acted unprofessionally in treating a family member Your family physician should have made arrangements for coverage Question 20: Professionalism – interactions with patients You are an unmarried physician. new to the region. Later the patient’s separated spouse learns of this and makes a complaint to the regulatory authority (College). Which statement is true? Choose one answer: A) B) C) D) E) Romantic and sexual relationships between physicians and current patients are forbidden This relationship is understandable as you have recently moved to the area Complaints to a College are ignored if they are not made by the patient As long as you have a chaperone when seeing this patient in the office. Because your family doctor is not available and you know the emergency department will be busy. you write a prescription for a narcotic and take it to the pharmacy. The two of you go on a dinner date. You are later notified by the regulatory authority (College) that the pharmacist has made a complaint.Question 19: Professionalism – treating family members During a statutory holiday long weekend your spouse develops a severe headache.