FISHER PDF. Pointer in deciding on the most effective book Kaplan Medical USMLE Medical Ethics: The Cases. You Are Most Likely To See On By Conrad. Kaplan Medical USMLE Medical Ethics: The Cases You are Most Likely to See on the Test (Kaplan USMLE): Medicine & Health Science. Master the Boards USMLE Medical Ethics by Conrad Fischer, , available at Book Depository with free delivery worldwide.
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book by Conrad fisher cases in medical ethics. USMLE"Medical The YouAreMost on the ConradFischer,M.D. AssociateChiefof. Features: Coverage of ethics and legalities surrounding the major issues most likely to be covered on the Ethics section of Steps 2 and 3 of USMLE and the. In this article, we are sharing with our audience the genuine PDF download of Kaplan Medical USMLE Medical Ethics PDF using direct links.
Ethics questions also appear on the internal medicine board exams, and other specialty boards. Medical ethics topics account for half the Behavioral Science questions on Step 1 and are perceived as the most difficult questions on Step 3. This book will guide you through these challenging questions. The book you have in your hands is a profoundly practical document that includes the most likely questions you will encounter on USMLE, practice questions, and the most relevant text in the area of medical ethics. This book is to help you get the questions right on the Boards—all the questions. Professional medical ethicists will not like our approach, which is to be concrete and definite.
He sayshewantsthe ventirarorrn. Overall, this caservill be ,h" ";;i.: Shehasthecapacityto understandthatshewill ai. Vhatdoyou tellher?
She problcms. For example, an HlV-positive,lehovah,s Witness who is now pregnant needs atransfusion to live and haye a deprcssedandisfuuyalert.
A at lc bi!!!! Yon cannot transfuse! The situatior. The fact that the patient is pregnantdoesno1alter the ansrver. Theprevailingconsensusis that personhoodbeginsaftcr birth. Until delivered,the fetus isconsidcredanother part of thc mother's boclv.
Another wrong ansrverwould be uaitinguntil the paticnt is no longer consciousand then transfusingher. Theanslversto all of the examplesdescribedin this scctionare clearbecausein eachcase thepatientis an adult rvith the capacitl,to understandhis or her nredicalproblems. If the casedescritresdeprcssionin the patientthenyou shouldchoosepsychiatricconsultation,or choosea trial of cither belravjoral therapv or antidepressantntedication asthe ansrvcr.
Patientshavethc right to try therapyfor a while ald thcn stop it if it doesnot suit then]. This is true even if it means they will clie from stopping dialysis, mechanical vcntila tion, HIV medications,or blood transfusions. The typc of treatnlent does not change the answer.
A CBC or cardiac bypass is ethically antl lcgally indistinguishable. Therefore,in a scnsc,treatinga paticr. Thereis no distinction betweenwithholding anclwithdrarving care. If you are doing sonc thing the patient does not ''ant,you cannot sa,v, "We11, sorry, but I already started, and I rcallvhaveto continuc.
The aclvance directiveis a by procluct of the successof nredical thcrapies such as the mechanical vcn tilator that can kccp a patient alive when in the past he would have cliecl. Becauseof thcse therapies,doctorsarenorv in the position of trying 1qictcmine u,hateachpatientwantcd for himself in terms of his health carc.
Thc advancedirectivcis part of the conceptof autonomy. The advancedirectiyetellsthc physicianrvhatthe paticnl'swishesaresothat the lcssaccurateforms of dccisionmcLking,suchassubstitutedjudgn. End-of-Lifelssues J 27 ical l b e Ling tor ntt no!! F Health-CareProxv The ttvo most comnon forms of aclvancedirectives are the living will and the health carc pror: The conceptof a,durablc,,powerofattorDey is critical becausethe word "durabre" means it remains in effect evenafter the patient roses decision-making capacity becauseof medical illness.
Other forms of legal proxics, such as a finar. The health carc prorT is a person chosenspecificallyby the patient to 'lake health-caredecisionsfor her in the evcnt that she cannot make decisions for hcrseH T'hesedecisions are limited to health care,not finance. Advance directive docunents ntay also have written instructions to give boundariesto care. For cxample,. However, the main focus of the proxy is to designate a person of "agent" who speaksto the physician regarding consent issuesfor aI treatments and tests,aswell asdiscussesissuesof withdrawing and withholding treatment.
The proT speaksfor the patient. Becausethe patient chooses the prorT as her representative,the proxy overrules all other decision ntakers. Therc is a strong presumption that the proxy knows the patient's wishes. The proxy is not there to give his personal opinion as to what he thinks should be done for tl. The proxy is there to communicate the patient,s originalwishcsin order to ensurethat they arecarriedout.
The pror: The proxy is also like a waiter. The patient tells the waiter lvhat kind of food he wants to eat what kind of medicines and testshe rvants. The proxT praccsthc order ir. The prory is not there to alter. The proxy makcs dccisionsbasedon rwo paranteters: Theprox,voutweighsall othcr potcntjal dccisionmakcrs,including thc family. For example, a year-old nar arrives at the emergency department febrile, shortof breath, and confused.
Many family men. The physician 'lvantsto perform an emergency lumbar puncture, which the patient's wife and siblingsare refusing. His year-old granddaughter r,valksup r'vith a health-care prorylbrm signedby the patient designating her asthe proq'.
Sheinsiststhat you dotheiumtrar puncture stating that washer understanding ofthe patient's wishes. Therestof the family, including the wife, refusesthe lumbar puncture stating that theyknorv the patient's wishesbetter. What do 1'oudo? You cannot tell ivhoin a family knows the paticnts wishesbest unlessthe patient is awaketo tell 1'ou. The prox,vdesignationis thc patient's wa. In the absenceof an advancc directive there is a list of relative importance in terms of surrogatedecisionnakcrs.
You should start first with the spouse,then parents,then adult children,then siblings,tl. This is an approximation only. When the family is split and there is no proxy, you nrust reterto lhcclhic. LivingWill A living will is a written form of advance directive that outlines the care that a patient l,ould want for herself if she were to lose the ability to communicate or the capacity to undcrstandher medicalproblen.
The etiologyof the lossof decision-makingcapacityis irrelevant. A living will can range from being an extremely precise document outlining the exact typesof care that a patient wants or does not want all the way to being a vague, useless documentthat makesnonspecificstatementssuchas "no heroic care.
I oes that mean a yentilatoror chemothcrapy,or dialysis,or bloocitcsts,or all of thcnr, or none of thenr? For instance,a living will that says"No intubatior, no cardiopulmonaryrcsuscitatron,no dialysis,and no blood transfusions" is vcry Lrsefuland allotvs fbr easyfollowinq. For example, a year-old woman ts admitted with metastatic cancer Jeaclingto a changein mcntal status secondaryto hypercalcenria.
Shehas a lir. I alsodo not wish to reccivedialysis. Blood tcstingand antibioticsareacceptable.
In the cascabove' follon' the directio' of the living will ancrcarry out the patient's wishes. A livi'g rvill woulcl overrurethe wishesof the fanrily beca,sctrrc riving will conmunicates the patieDt'so. As a nlatter of autonon ,, the patient! Thc rnajorissue'ith the useof a living will is that it is very difficult, ur advanceof trre'r- ness,to be celtain which medical treatmer. NoCapacityandNoAdvanceDirectives Here is u'hat is vcry ciear atrout withholding and withclrarval of caredecisions: End-of-LifeIssues I 5 l ot -lo at of tS a IO Llnfortunately,the 'ast majority of patients, e'en at oldcr age a'd with life-threatening illnesses,do not havea formal advancedirective.
Decision making ca' be rmLchmo.. Ifthe family is united and in agreement,then there is 'o difficulty llith making decisions for the patient. The main issueagain comes to clemonstratjng tlte bestevidenccof lctowing the patier. Forexample, a 64 year-old man suff-ersa severeiltracrallial bleed leavir]s him conatoseand paralyzed. His wife, sister,and four chjldren arc in the horpital.
Theycome to seeyou bccausethey are unanimously asking that you remove the endotrachealtube and lcavethe patient to die. The patient repcatedlymadc this rvishknown to his family. What shoulclyou do? The patient has the right to refuseit. For example, a year old wouran has been aclmitted to a nursing homc with adyanceddementia. Shehasdifficulty maintaining oral intake sufficient to survive. Thenursinghome wantsto placea nasogastrictutrefor-fecding.
The husbandand the son expresslystatethat the patient slid she. Arethe family members passinplon information about what the patient said, or are thev tellingyou to do what the1,think is bcst fbr the patient? Having a fan]ily memberexpressa patient's wishes is equivalent to having him cast a vote on the patient,s behall If a person cannot speak,another person can mail in her vote for her if she has clearlytold this person which candidate shervants to vote for.
If she told her brother that lvantedto vote republican and he sendsin her ballot stating this, then he is acting on her Likewise,if hek'ows what shewantsbecauseshetorrlhim, then he canstopthe ventilator,the blood tcsting,the. EthicsCommitteeandReferraltotheCourts ihen there is no clear adyancedirective and the family does not agreeon what the patient wanted for hin.
Hcre is a list of thc various kinds of consent,with the most desirablelisted first: Direct patient rvishverbalizedby the patient. Forrnaladvancedircctivesuchasa proxy or a living will. Oral advancedirective. United group of fimily and friends.
Croup of family membersdisagreeingon what thc patient would havewanted In caseswhere there is no living will or proxy and the family members are not in agreement,: The last step to pursue in the absenceof a clear consensusis relerral to the courts or "seekjudicial intervention.
The patientt parents stated that she never saiclthat. The ethics:: Deathof breath. DNRdoesnot mean patientssh resuscitation. Apatint trhenpatientshavecardiopuln. I intubated and maintained on a ventilator if sheis DNR. This is a confusing point because endotrachealintubation is often a part of the normal resuscitativeprocess.
Hon'ever,ifthe patient remains alive and has advancing lung disease,the patient can still be intubated ln. Doctors Jo not have ' to rernovethe endotrachealtube of all patients who chooseto be DNR. Many patients will not allow themselvesto be made DNR becausethey believethe medical staff will not beas aggressivein their other treatments.
For example,a 68 year-oldman with basalcellcanceris aclmittedfor evaluation andtreatmentof a fever. He hasbecnDNR for thelastsixmonths. After the chest X ray,urinal 'sis,andblood culturearedonehestill hasafeverof unknownetiol ogy.
When you askthe residentwhy he hasn'tdone more tests,the responseis, "Well, wervill getto it, but thereisn'tmuchof arush,alierall,thcpatientisDNR. In thiscase,it wouldalsoeliminateendotrachealintubationif this treatmentwerepart of the resuscitativceffort. That is all. Thedoctoris expectedto man- agepain andthe diaplnosisof othermedicalproblemsjust asaggressivelyasshewouldin a non-DNR patientunlessthepatienthasspecificallychosento deferthoseotherformsof therapy. Doctorsdo not automaticallyhaveto havethc DNR orderrcversedjust to bein the intensivecareunit or to goto surgery.
Sastric'or jejunostomy turre pracement. What shouldyou tell her? Forcibleinscrtionby anyoneof an artificial feedingdeviceinto an adurtpatientwith thecapacityto understandthe meaningof its rcmovalis not allowed.
If the patient,swishesareclearlyexprcsscd,thisisthesamcasrefusingaventilator,bloodtesting,or dialysis. Thisrefusalis subjectto the samecriteriaasthe refusaiof oth", tl. If thereis no depression,tn"n tn.
We canneverwithhold ordinarynutrition like foodtoeatandwaterto drink. The stanclardof certaintyregardinga patientt wishesin termsof. If there is a health-care proxy, and thc healthcare agent says, "The patient clearly told me that they didn't want tube feeds,"you nay withhold the therapy. If there is a living will rvhere the patient themselveswrote, "I do not tvish to have a nasogastric tube or other forms of artificial nutrition," you may withhold the therapy.
If clear wishesregarding fluids and nutri- tion were ncver clearly expressed,thcn there is inplied consent for the feeding basedon the presumption that it would be the patient's wish to be fed and on the f-actthat feeding and hydration are in thc patient's best interest. Emotionally, the standard is different from the standard used to dcternrine whether or not ordinary testing such as blood tests or CT scansshould be donc. The proxy and fanily can say, "The patient never specifically told rne that he would not want a liver biopsy or MRI of the brain, but mv understanding of his wishcs in generalis that he doesn't want to undergo theseprocedurcs.
Decisions on with- holding and withdrawing of artificial fluids and nutrition should bc treated the sameway asany other medical treatnent. There is a higher standard of evidencefor decision making in some states.
That is why this issueis so complex. Fcw people have left a specific,written document concerningtheir desirefor tube feecling. The evidence has to be clear that a paticnt does not want artificial nutritjon.
Thc routine assumption is that rnost people wish to be fed asa part of ordinary care. If the evidenceis not clear,then a referral to an ethics comnittee, or possibly to the courts, is necessary.
The level of evidence regarding the patient's wishes necessaryfor withholding and withdraw- ing artificial nutrition hasbeen treated by some courts asthe sameasthe level of evidence required in a criminal case. The system errs on the sidc of caution-perhaps letting a few guilty people go free rather than sending a single innocent person to jail or execution. If you lost consciousnesssuddenly and left no specific instructions, wouldn't you want there to be a need fbr colrvincing evidence that you didn't want to be fed before your relatives rvere able to withhold nutrition and possibly let you die?
Ethical consensusholds that decisiolrs to provide or forgo artificial nutrition and hydration ANH for patients who lack capacity should be made according to thc same standardsasthose uscd for any other medical treatment. Despite this consensus,ccrtain statesimpose more stringent standards for withholding or withdrawal of ANH compared to other medical trearmenrs. End-of-Lifelssues I me vill hcr ive, to. The doctor doesnot actuallyaclministerthe substancethat endsthe patient's life. Thisis true even if there is a local state law permitting the procedure.
W1rat is legal does n0tautomaticallyequal rvhat is ethical. Generally,physician assistedsuicide is requestedby patientswho havea terminal diseaseand a limited life expectancyanyway. Neverthelcss,the severityof the diseaseand eventhe discomfortand sufferingof the patient do not change theansu,er. The primaryissueis one of intent.
Physician assistedsuicide is inimical, or absolutelycontrary, to the role of the physician to savelife. This is true even if thc patient is requesting the assistance. A physician cannot ethically honor a patient's wishcs to bc provided with the meansto end his life. Euthanasia actually means that the health-care worker is prescribing and administeringthe method of death. Thele is no place in the United Stateswhere eutha- nasiais legal. A physician cannot legally administer a lethal injection or any other form of therapythat will help end life.
This is true even if the patient is preterminal. Fluthanasiais cthicallyunacceptable.
The issueis one of intent. If theintent is to end life, it is wrong. If thc intent is to relievesuffering and accidentally-as anunintended effect-the patient's life is shortened,then the treatment is acceptable.
This is comparable to the differencc bctwcen a charitable donation and being robbed. If I give S1,to charityto help othersit is avirtue. IfI stealevenonedollar from you,it is a crime. Both eventsresult in thc transfer of monev. For example, a 67 year old man is admitted with metastaticprostate cancerto the bones. He is in cxcruciating pain despiteyour present treatment. He has a history ay..
I chapterFive t! What shoulcll. Theprimary ethicalduty is to rclievesuffering. Thisistrueevenif thepatientor the familyisdemandingit. It is hardalwaystr becertainif the treat'rent rvill not herp.
If it isclearthattherewill beno benefitthcnyoushoLrldnot qiveit. For example,a 57 year-oldwoman with cryptogeniccirrhosisis uncleryour care. Sheis septicandhassevcrevaricealbleedingaswellasencephalopathvnot respondingto lactulose.
Sheis hypotensiveand on pressorsaslvell asintubated from respiratoryfailure and you expecther to die from her liver diseasein the next few days. ShedevelopsHepatorenalsyndromeand hasdevelopeduremia. The family is requestingplacementof a fistulafor rlialysis. What shouldyou tcll them? In this case,thereisa clearurderlying preterminarcondition. Dialysisin this casewi not changethe outcome. DirJysisin this casc would not prolong meaningfullife.
Becausein this casetlialysisrvouldonly prolong the dyingprocess,withholdingit is ethical,evenif thefamily is requestingn.
End-of-Lifetssues I i9 t sLife, drive. If For example, a man is arrested fcrr arrned robbery in which hc assaultsanothcr man. The victim has sustained cerebral hcrniation and has lost all spontaneous respirations,cognitive function, and brainstem reflexes.
The allegedassailant,sclefenselawyer tellsthe. The defcnselawyer contends that the victim can bc alivefor many ycars ir. The penaltyfor assaultmay be onlv l0 to 20 yearsin prison. What shoulcl vou tell the juclge? Braindeath is the legal definition of death. An assaultleading to brain death is a murder. Braindeathis irreversibleand permanent. A bcatingheart that maintainsbrood pressure andpulse does not equal being alivc.
When wc, as physicians, determine the criteria for braindeath are present,this is the legally acceptedstandard of death. Braindeathis a lossof brainstemreflexessuchas: I Pupilary light reflex Cornealreflexes Oculocephalic doll's cyes reflexes Calotic responsesto icedrvaterstintulation of the tynrpanic membrane fhe. In other words, the clinical criteria of the absenceof breathins and brainstcmreflexesaremore important than an EEG. This is becauseEECactivitywou]d be of limited mcaning if a patier.
Braindcath should only be determined to be present if you have excluded other causes of markedly decreasedbrainstem and rcspiratory function.
Thesecanall simulatebrain death. For example, a year-old yroman is admitted aftcr having a serzurear a parr i. HerheadCT scanshowsan intracranialbleed. Sheis intubatedbecauseof the loss of spoDtaneousrespiration. Therearc no pupilary,corneal,oculocephalic,or cold caloric reflexeselicited. Which of the follorving shoultl you clonext? An EKG j nosedeathat anypoint. Auscultationof the heartis all ,h", i,..
Brain deathdoesnot specificallyrequiredeterminationby a neurologistif the physician managingthe patientis comfortablewith the criteriadescribedanclhow to verify them.
Thisis similarto not needingapsychiatristin orderto determinccapacity. If thepatientisclearlynot braindeadbecausetheirpupilsarcreactiveor theyhavespontaneousbreathing, a neurologistis unnecessary. If thepatientisbrain dead,thentheyaredead.
Thephysiciandoesnor needa court orderor a relative'spern.
Thedoctordoesnot needto askanyone,spermissionto stop the ventilatoror. Insurancecompanreswillnot pay for the hospitalizationor managcmentof thosepatientswl. Actually,it ispreferableto removetheorganswhiletheheart isstill beatingbecausetheviabilityof th" t.
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