Informed consent

Informed consent US Medical PG Question 1: A 68-year-old man comes to the physician for a follow-up examination, accompanied by his daughter. Two years ago, he was diagnosed with localized prostate cancer, for which he underwent radiation therapy. He moved to the area 1 month ago to be closer to his daughter but continues to live independently. He was recently diagnosed with osteoblastic metastases to the spine and is scheduled to initiate therapy next week. In private, the patient’s daughter says that he has been losing weight and wetting the bed, and she tearfully asks the physician if his prostate cancer has returned. She says that her father has not spoken with her about his health recently. The patient has previously expressed to the physician that he does not want his family members to know about his condition because they “would worry too much.” Which of the following initial statements by the physician is most appropriate?

• A. “As your father's physician, I think that it's important that you know that his prostate cancer has returned. However, we are confident that he will respond well to treatment.”
• B. “I'm sorry, I can't discuss any information with you without his permission. I recommend that you have an open discussion with your father.” (Correct Answer)
• C. “It concerns me that he's not speaking openly with you. I recommend that you seek medical power of attorney for your father. Then, we can legally discuss his diagnosis and treatment options together.”
• D. “It’s difficult to deal with parents aging, but I have experience helping families cope. We should sit down with your father and discuss this situation together.”
• E. “Your father is very ill and may not want you to know the details. I can imagine it's frustrating for you, but you have to respect his discretion.”

Informed consent Explanation: ***“I'm sorry, I can't discuss any information with you without his permission. I recommend that you have an open discussion with your father.”*** - This statement upholds **patient confidentiality** and **autonomy**, as the patient explicitly stated he did not want his family to know about his condition. - It encourages communication between the patient and his daughter, which is the most appropriate way for her to learn about his health status. *“As your father's physician, I think that it's important that you know that his prostate cancer has returned. However, we are confident that he will respond well to treatment.”* - This violates the patient's **confidentiality** and explicit wish to keep his medical information private from his family. - Sharing medical information without explicit consent, even with family, is a breach of ethical and legal guidelines (e.g., **HIPAA** in the United States). *“It concerns me that he's not speaking openly with you. I recommend that you seek medical power of attorney for your father. Then, we can legally discuss his diagnosis and treatment options together.”* - While seeking medical power of attorney is an option for future decision-making, it is **premature and inappropriate** to suggest it solely to bypass the patient's current desire for confidentiality, especially when he is still competent to make his own decisions. - This suggestion could undermine the patient's autonomy and trust in his physician. *“It’s difficult to deal with parents aging, but I have experience helping families cope. We should sit down with your father and discuss this situation together.”* - This statement, while empathetic, still risks undermining the patient's **autonomy** by pushing for a joint discussion against his explicit wishes to keep his family unaware. - The physician's primary obligation is to the patient's stated preferences regarding his medical information. *“Your father is very ill and may not want you to know the details. I can imagine it's frustrating for you, but you have to respect his discretion.”* - While this statement acknowledges the daughter's feelings and respects the patient's discretion, it uses a somewhat **judgmental tone** ("very ill") and the phrasing "you have to respect his discretion" can come across as abrupt or dismissive rather than purely informative or guiding. - The most appropriate initial response should focus on the **physician's inability to share information** due to confidentiality rather than attributing motives to the patient's decision or explicitly telling the daughter how to feel.

Informed consent US Medical PG Question 2: A 42-year-old woman presents to the physician with symptoms of vague abdominal pain and bloating for several months. Test results indicate that she has ovarian cancer. Her physician attempts to reach her by phone multiple times but cannot reach her. Next of kin numbers are in her chart. According to HIPAA regulations, who should be the primary person the doctor discusses this information with?

• A. The patient's brother
• B. The patient's husband
• C. The patient's daughter
• D. All of the options
• E. The patient (Correct Answer)

Informed consent Explanation: ***The patient*** - Under **HIPAA**, the patient has the **right to privacy** regarding their protected health information (PHI). Therefore, the physician must make all reasonable attempts to contact the patient directly to convey their diagnosis. - Sharing sensitive medical information like a cancer diagnosis with anyone other than the patient, without their explicit consent, would be a **violation of HIPAA regulations**. *The patient's brother* - The patient's brother is not automatically authorized to receive her medical information, even if listed as **next of kin**, without the patient's explicit consent or a documented **healthcare power of attorney**. - Discussing the diagnosis with the brother without the patient's direct consent would be a **breach of patient confidentiality**. *The patient's husband* - Even a spouse does not automatically have the right to access a patient's **PHI** without the patient's express permission, according to **HIPAA**. - While often a trusted contact, without explicit consent, revealing the diagnosis to the husband would still violate the patient's **privacy rights**. *The patient's daughter* - Similar to other family members, the patient's daughter is not legally entitled to receive her mother's confidential medical information without explicit authorization or a medical **power of attorney**. - The physician's primary responsibility is to the patient herself, ensuring her **privacy** is maintained. *All of the options* - According to **HIPAA**, sharing the patient's diagnosis with any family member without her explicit consent would be a **breach of confidentiality**. - This option incorrectly assumes that **next of kin** automatically have the right to receive sensitive medical information.

Informed consent US Medical PG Question 3: A 29-year-old man is admitted to the emergency department following a motorcycle accident. The patient is severely injured and requires life support after splenectomy and evacuation of a subdural hematoma. Past medical history is unremarkable. The patient’s family members, including wife, parents, siblings, and grandparents, are informed about the patient’s condition. The patient has no living will and there is no durable power of attorney. The patient must be put in an induced coma for an undetermined period of time. Which of the following is responsible for making medical decisions for the incapacitated patient?

• A. The spouse (Correct Answer)
• B. An older sibling
• C. Physician
• D. Legal guardian
• E. The parents

Informed consent Explanation: ***The spouse*** - In the absence of a **living will** or **durable power of attorney**, the law typically designates the **spouse** as the primary decision-maker for an incapacitated patient. - This hierarchy is established to ensure decisions are made by the individual most intimately connected and presumed to understand the patient's wishes. *An older sibling* - Siblings are generally further down the **hierarchy of surrogate decision-makers** than a spouse or parents. - They would typically only be considered if higher-priority family members are unavailable or unwilling to make decisions. *Physician* - The physician's role is to provide medical care and guidance, not to make medical decisions for an incapacitated patient when family surrogates are available. - Physicians only make decisions in **emergency situations** when no surrogate is immediately available and treatment is immediately necessary to save the patient's life or prevent serious harm. *Legal guardian* - A legal guardian is usually appointed by a **court** when there is no appropriate family member available or when there is a dispute among family members. - In this scenario, with a spouse and other close family members present, a legal guardian would not be the first choice. *The parents* - While parents are close family members, they are typically considered **secondary to the spouse** in the hierarchy of surrogate decision-makers for an adult patient. - They would usually only be the decision-makers if the patient were unmarried or the spouse were unavailable.

Informed consent US Medical PG Question 4: A 54-year-old man suffered an anterior wall myocardial infarction that was managed in the cath lab with emergent coronary stenting and revascularization. The patient states that his wife, adult children, and cousins may be disclosed information regarding his care and health information. The patient has been progressing well without any further complications since his initial catheterization. On hospital day #3, a woman stops you in the hall outside of the patient's room whom you recognize as the patient's cousin. She asks you about the patient's prognosis and how the patient is progressing after his heart attack. Which of the following is the most appropriate next step?

• A. Decline to comment per HIPAA patient confidentiality regulations
• B. Direct the woman to discuss these issues with the patient himself
• C. Ask the patient if it is acceptable to share information with this individual
• D. Discuss the patient's hospital course and expected prognosis with the woman
• E. Ask for identification confirming that the woman is truly the patient's cousin (Correct Answer)

Informed consent Explanation: ***Ask for identification confirming that the woman is truly the patient's cousin*** - While **HIPAA** emphasizes patient privacy, it also allows disclosure to family members if the patient has agreed to it or if disclosure is deemed in the patient's best interest. - The patient explicitly stated that his cousins may be disclosed information; therefore, confirming the woman's identity as a cousin is the most **appropriate first step** to determine if she is one of the individuals he approved for information disclosure. *Decline to comment per HIPAA patient confidentiality regulations* - This is an overly broad and potentially **unnecessary response**, as the patient has already indicated that his cousins can receive information. - **HIPAA allows for disclosure** to family members or others involved in the patient's care if the patient expresses a preference or does not object. *Direct the woman to discuss these issues with the patient himself* - This option **shifts the responsibility** of disclosure from the healthcare provider, who holds the medical information, to the patient. - While the patient can certainly share his own information, the family may be seeking **professional medical updates** that the patient might not be fully equipped to provide. *Ask the patient if it is acceptable to share information with this individual* - Although obtaining direct patient consent is generally a good practice, the patient has already **verbally authorized family members**, including cousins, to receive information. - The primary outstanding issue is confirming this specific individual's relationship to the patient, rather than re-asking for permission to share with cousins in general. *Discuss the patient's hospital course and expected prognosis with the woman* - This action would be **premature and a violation of HIPAA** if the woman cannot be confirmed as the patient's cousin. - **Verification of identity** and relationship is crucial before disclosing any protected health information.

Informed consent US Medical PG Question 5: A 15-year-old teenager presents to the emergency department via emergency medical service (EMS) after a motor vehicle accident. The patient is in critical condition and is hemodynamically unstable. It becomes apparent that the patient may require a blood transfusion, and the parents are approached for consent. They are Jehovah’s Witnesses and deny the blood transfusion, saying it is against their beliefs. However, the patient insists that she wants the transfusion if it will save her life. Despite the patient’s wishes, the parents remain steadfast in their refusal to allow the transfusion. Which of the following is the most appropriate course of action?

• A. Obtain a court order to give blood products. (Correct Answer)
• B. Give the patient the blood transfusion.
• C. Give intravenous fluids to attempt to stabilize the patient.
• D. Do not give blood transfusion due to the parents’ refusal.
• E. Consult the hospital ethics committee.

Informed consent Explanation: ***Obtain a court order to give blood products.*** - In situations where a minor's life is at risk and parents refuse life-saving treatment, seeking a **court order** is the most appropriate action to protect the child's best interests. - This step allows the medical team to proceed with the necessary treatment despite parental objections, balancing the parents' religious freedom with the state's interest in protecting children. *Give the patient the blood transfusion.* - Directly proceeding with the transfusion without legal intervention against parental wishes for a minor could lead to **legal ramifications** and accusations of battery or lack of informed consent. - While the patient expresses a wish for the transfusion, due to her minor status, parental consent or a court order is generally required before proceeding against parental refusal. *Give intravenous fluids to attempt to stabilize the patient.* - While supportive measures like **intravenous fluids** are important, they may not be sufficient to stabilize a hemodynamically unstable patient requiring a blood transfusion. - Delaying definitive, necessary treatment in a critical situation can worsen the patient's condition and is not a substitute for addressing the need for blood products. *Do not give blood transfusion due to the parents’ refusal.* - Refusing to provide life-saving treatment to a minor when a less invasive alternative is unavailable, solely based on parental religious beliefs and despite the child's expressed wishes, could be considered **medical neglect** and runs contrary to the medical obligation to preserve life. - Even if the parents are steadfast, the healthcare team has an ethical and legal obligation to advocate for the minor's well-being, especially when the minor explicitly requests the treatment. *Consult the hospital ethics committee.* - While an **ethics committee** consultation is valuable for complex ethical dilemmas, it is typically a time-consuming process that may not be feasible for a critically ill, hemodynamically unstable patient requiring immediate intervention. - In urgent, life-threatening situations involving minors, the immediate priority is to secure the necessary treatment, often through direct legal channels, rather than waiting for an ethics committee review.

Informed consent US Medical PG Question 6: A 79-year-old man with a history of prostate cancer is brought to the emergency department because of lower abdominal pain for 1 hour. He has not urinated for 24 hours. Abdominal examination shows a palpable bladder that is tender to palpation. A pelvic ultrasound performed by the emergency department resident confirms the diagnosis of acute urinary retention. An attempt to perform transurethral catheterization is unsuccessful. A urology consultation is ordered and the urologist plans to attempt suprapubic catheterization. As the urologist is called to see a different emergency patient, she asks the emergency department resident to obtain informed consent for the procedure. The resident recalls a lecture about the different modes of catheterization, but he has never seen or performed a suprapubic catheterization himself. Which of the following statements by the emergency department resident is the most appropriate?

• A. “I would prefer that you obtain informed consent when you become available again.” (Correct Answer)
• B. “Suprapubic catheterization is not the treatment of choice for this patient.”
• C. “I would be happy to obtain informed consent on your behalf, but I'm not legally allowed to do so during my residency.”
• D. “I will make sure the patient reads and signs the informed consent form.”
• E. “I will ask the patient to waive informed consent because this is an urgent procedure.”

Informed consent Explanation: ***"I would prefer that you obtain informed consent when you become available again."*** - Informed consent requires that the person obtaining consent be **knowledgeable about the procedure**, its risks, benefits, and alternatives, and be able to answer the patient's questions thoroughly. The resident, having never performed or seen the procedure, cannot fulfill this requirement. - The urologist, as the attending physician performing the procedure and the expert in suprapubic catheterization, is the most appropriate person to **educate the patient and obtain consent**. *"Suprapubic catheterization is not the treatment of choice for this patient."* - **Urethral catheterization is the first-line treatment for acute urinary retention**; however, it was unsuccessful. - **Suprapubic catheterization is the appropriate next step** when transurethral catheterization fails or is contraindicated. *"I would be happy to obtain informed consent on your behalf, but I'm not legally allowed to do so during my residency."* - There is **no legal prohibition** for a resident to obtain informed consent, provided they are competent to do so and have adequate knowledge of the procedure. - The issue here is the resident's **lack of knowledge and experience** with the particular procedure, not their legal status as a resident. *"I will make sure the patient reads and signs the informed consent form."* - Simply having the patient read and sign a form is **insufficient for valid informed consent**. - Informed consent is a **process of communication** that ensures the patient understands the procedure, not just a signature on a document. *"I will ask the patient to waive informed consent because this is an urgent procedure."* - While this is an urgent situation, it is **not an emergency that precludes obtaining informed consent**. - **Waiving informed consent** is generally reserved for life-threatening emergencies where immediate intervention is required to save a patient's life and there is no time to obtain consent, which is not the case here.

Informed consent US Medical PG Question 7: A 28-year-old woman dies shortly after receiving a blood transfusion. Autopsy reveals widespread intravascular hemolysis and acute renal failure. Investigation reveals that she received type A blood, but her medical record indicates she was type O. In a malpractice lawsuit, which of the following elements must be proven?

• A. Duty, breach, causation, and damages (Correct Answer)
• B. Only duty and breach
• C. Only breach and causation
• D. Duty, breach, and damages

Informed consent Explanation: ***Duty, breach, causation, and damages*** - In a medical malpractice lawsuit, all four elements—**duty, breach, causation, and damages**—must be proven for a successful claim. - The healthcare provider had a **duty** to provide competent care, they **breached** that duty by administering the wrong blood type, this breach **caused** the patient's death and renal failure, and these injuries constitute **damages**. *Only duty and breach* - While **duty** and **breach** are necessary components, proving only these two is insufficient for a malpractice claim. - It must also be demonstrated that the breach directly led to the patient's harm and resulted in legally recognized damages. *Only breach and causation* - This option omits the crucial elements of professional **duty** owed to the patient and the resulting **damages**. - A claim cannot succeed without establishing that a duty existed and that quantifiable harm occurred. *Duty, breach, and damages* - This option misses the critical element of **causation**, which links the provider's breach of duty to the patient's injuries. - Without proving that the breach *caused* the damages, even if a duty was owed and breached, and damages occurred, the claim would fail.

Informed consent US Medical PG Question 8: A psychiatrist receives a call from a patient who expresses thoughts of harming his ex-girlfriend. The patient describes a detailed plan to attack her at her workplace. Which of the following represents the psychiatrist's most appropriate legal obligation?

• A. Warn the ex-girlfriend and notify law enforcement (Correct Answer)
• B. Only notify the patient's family
• C. Warn only law enforcement
• D. Maintain patient confidentiality

Informed consent Explanation: ***Warn the ex-girlfriend and notify law enforcement*** - This scenario directly triggers the **"duty to warn"** and **"duty to protect"** principles, primarily stemming from the **Tarasoff v. Regents of the University of California** case. - The psychiatrist has a legal obligation to take reasonable steps to protect the identifiable victim, which includes directly warning the intended victim and informing law enforcement. *Only notify the patient's family* - Notifying the patient's family alone does not fulfill the **legal obligation to protect** an identifiable third party from a serious threat of harm. - While family involvement might be part of a comprehensive safety plan, it is insufficient as the sole action in this critical situation. *Warn only law enforcement* - While notifying law enforcement is a crucial step, the **Tarasoff duty** specifically mandates warning the **intended victim** directly (or those who can reasonably be expected to notify the victim). - Relying solely on law enforcement might not ensure the immediate safety of the ex-girlfriend, especially if there's a delay in their response or ability to locate her. *Maintain patient confidentiality* - Patient confidentiality is a cornerstone of psychiatric practice, but it is **not absolute** when there is a serious and imminent threat of harm to an identifiable individual. - The **duty to protect** a potential victim *outweighs* the duty to maintain confidentiality in such extreme circumstances.

Informed consent US Medical PG Question 9: An epidemiologist is evaluating the efficacy of Noxbinle in preventing HCC deaths at the population level. A clinical trial shows that over 5 years, the mortality rate from HCC was 25% in the control group and 15% in patients treated with Noxbinle 100 mg daily. Based on this data, how many patients need to be treated with Noxbinle 100 mg to prevent, on average, one death from HCC?

• A. 20
• B. 73
• C. 10 (Correct Answer)
• D. 50
• E. 100

Informed consent Explanation: ***10*** - The **number needed to treat (NNT)** is calculated by first finding the **absolute risk reduction (ARR)**. - **ARR** = Risk in control group - Risk in treatment group = 25% - 15% = **10%** (or 0.10). - **NNT = 1 / ARR** = 1 / 0.10 = **10 patients**. - This means that **10 patients must be treated with Noxbinle to prevent one death from HCC** over 5 years. *20* - This would result from an ARR of 5% (1/0.05 = 20), which is not supported by the data. - May arise from miscalculating the risk difference or incorrectly halving the actual ARR. *73* - This value does not correspond to any standard calculation of NNT from the given mortality rates. - May result from confusion with other epidemiological measures or calculation error. *50* - This would correspond to an ARR of 2% (1/0.02 = 50), which significantly underestimates the actual risk reduction. - Could result from incorrectly calculating the difference as a proportion rather than absolute percentage points. *100* - This would correspond to an ARR of 1% (1/0.01 = 100), grossly underestimating the treatment benefit. - May result from confusing ARR with relative risk reduction or other calculation errors.

Informed consent US Medical PG Question 10: A 28-year-old male presents to his primary care physician with complaints of intermittent abdominal pain and alternating bouts of constipation and diarrhea. His medical chart is not significant for any past medical problems or prior surgeries. He is not prescribed any current medications. Which of the following questions would be the most useful next question in eliciting further history from this patient?

• A. "Does the diarrhea typically precede the constipation, or vice-versa?"
• B. "Is the diarrhea foul-smelling?"
• C. "Please rate your abdominal pain on a scale of 1-10, with 10 being the worst pain of your life"
• D. "Are the symptoms worse in the morning or at night?"
• E. "Can you tell me more about the symptoms you have been experiencing?" (Correct Answer)

Informed consent Explanation: ***Can you tell me more about the symptoms you have been experiencing?*** - This **open-ended question** encourages the patient to provide a **comprehensive narrative** of their symptoms, including details about onset, frequency, duration, alleviating/aggravating factors, and associated symptoms, which is crucial for diagnosis. - In a patient presenting with vague, intermittent symptoms like alternating constipation and diarrhea, allowing them to elaborate freely can reveal important clues that might not be captured by more targeted questions. *Does the diarrhea typically precede the constipation, or vice-versa?* - While knowing the sequence of symptoms can be helpful in understanding the **pattern of bowel dysfunction**, it is a very specific question that might overlook other important aspects of the patient's experience. - It prematurely narrows the focus without first obtaining a broad understanding of the patient's overall symptomatic picture. *Is the diarrhea foul-smelling?* - Foul-smelling diarrhea can indicate **malabsorption** or **bacterial overgrowth**, which are important to consider in some gastrointestinal conditions. - However, this is a **specific symptom inquiry** that should follow a more general exploration of the patient's symptoms, as it may not be relevant if other crucial details are missed. *Please rate your abdominal pain on a scale of 1-10, with 10 being the worst pain of your life* - Quantifying pain intensity is useful for assessing the **severity of discomfort** and monitoring changes over time. - However, for a patient with intermittent rather than acute, severe pain, understanding the **character, location, and triggers** of the pain is often more diagnostically valuable than just a numerical rating initially. *Are the symptoms worse in the morning or at night?* - Diurnal variation can be relevant in certain conditions, such as inflammatory bowel diseases where nocturnal symptoms might be more concerning, or functional disorders whose symptoms might be stress-related. - This is another **specific question** that should come after gathering a more complete initial picture of the patient's symptoms to ensure no key information is overlooked.

Informed consent Flashcard 1 of 10

Question: Which ego defense is defined as demonstrating hostile feelings in a non-confrontational manner?_____

Answer: Passive aggression (immature defense)

Informed consent Flashcard 2 of 10

Question: Which stage of change is characterized by acknowledging there's a problem, BUT not yet ready or willing to make a change? _____

Answer: Contemplation

Informed consent Flashcard 3 of 10

Question: _____ is a type of conditioning where a natural response is elicited by a conditioned/learned stimulus that was previously presented with an unconditioned stimulus

Answer: Classical conditioning

Informed consent Flashcard 4 of 10

Question: The first line treatments for Enuresis are _____ modification and positive reinforcement

Answer: behavioral

Informed consent Flashcard 5 of 10

Question: Which stage of change is characterized by not yet acknowledging that there is a problem? _____

Answer: Precontemplation

Informed consent Flashcard 6 of 10

Question: Transcortical mixed aphasia is characterized by _____ repetition

Answer: intact

Extra Information:  https://onlinemeded.org/spa/neurology?ref=anki 

Informed consent Flashcard 7 of 10

Question: When considering Consent for Minors, situations in which parental consent is usually not required can be remembered by the mnemonic _____ Drugs (Substance Abuse) Rock and Roll (Emergency / Trauma)

Answer: Sex (Contraception, STIs, Pregnancy)

Extra Information: Watch associated Bootcamp video [https://app.bootcamp.com/med-school/public-health-sciences/videos/ethics?index=3] https://onlinemeded.org?ref=anki 

Informed consent Flashcard 8 of 10

Question: Does a healthcare proxy overrule all other decision makers regardless of family relationships? _____

Answer: Yes

Extra Information:  https://onlinemeded.org?ref=anki 

Informed consent Flashcard 9 of 10

Question: Exceptions for getting parental consent _____ Sex (contraceptives, STIs, pregnancy) drugs (substance abuse), rock & roll (emergency/trauma)

Answer: Married, self supporting (e.g. employed), or in the military

Extra Information:  https://onlinemeded.org?ref=anki 

Informed consent Flashcard 10 of 10

Question: If you're unsure if someone is competent, do we assume that he/she is competent? _____

Answer: Yes

Extra Information:  https://onlinemeded.org?ref=anki