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?

Duty, breach, causation, and damages

An 85-year-old man with terminal stage colon cancer formally designates his best friend as his medical durable power of attorney. After several courses of chemotherapy and surgical intervention, the patient’s condition does not improve, and he soon develops respiratory failure. He is then placed on a ventilator in a comatose condition. His friend with the medical power of attorney tells the care provider that the patient would not want to be on life support. The patient’s daughter disputes this and says that her father needs to keep receiving care, in case there should be any possibility of recovery. Additionally, there is a copy of the patient’s living will in the medical record which states that, if necessary, he should be placed on life support until full recovery. Which of the following is the most appropriate course of action?

The durable medical power of attorney’s decision should be followed.

Withdraw the life support since the patient’s chances of recovery are very low

Contact other family members to get their input for the patient

Act according to the patient’s living will

Follow the daughter’s decision for the patient

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?

Warn the ex-girlfriend and notify law enforcement

Only notify the patient's family

Maintain patient confidentiality

A 68-year-old woman was recently diagnosed with pancreatic cancer. At what point should her physician initiate a discussion with her regarding advance directive planning?

Now that she is ill, speaking about advance directives is no longer an option

Only if her curative surgical and medical treatment fails

Only if she initiates the conversation

A 72-year-old woman is brought to the emergency department by ambulance after an unexpected fall at home 1 hour ago. She was resuscitated at the scene by paramedics before being transferred to the hospital. She has a history of ischemic heart disease and type 2 diabetes mellitus. She has not taken any sedative medications. Her GCS is 6. She is connected to a mechanical ventilator. Her medical records show that she signed a living will 5 years ago, which indicates her refusal to receive any type of cardiopulmonary resuscitation, intubation, or maintenance of life support on mechanical ventilation. Her son, who has a durable power-of-attorney for her healthcare decisions, objects to the discontinuation of mechanical ventilation and wishes that his mother be kept alive without suffering in the chance that she might recover. Which of the following is the most appropriate response to her son regarding his wishes for his mother?

“Based on her wishes, mechanical ventilation must be discontinued.”

“We will take every measure necessary to prolong her life.”

“She may be eligible for hospice care.”

“The opinion of her primary care physician must be obtained regarding further steps in management.”

“Further management decisions will be referred to the hospital’s ethics committee.”

A 32-year-old woman is brought to the emergency department by her husband because of an episode of hematemesis 2 hours ago. She has had dyspepsia for 2 years. Her medications include occasional ibuprofen for headaches. After initial stabilization, the risks and benefits of upper endoscopy and alternative treatments, including no therapy, are explained thoroughly. She shows a good understanding of her condition and an appreciation of endoscopic treatment and its complications. She decides that she wants to have an endoscopy to find the source of bleeding and appropriately manage the ulcer. Her medical records show advance directives that she signed 3 years ago; her sister, who is a nurse, has a durable power of attorney. Regarding obtaining informed consent, which of the following is the most accurate conclusion for providing endoscopic treatment for this patient?

Documentation of her decision prior to treatment is required

There are reasons to believe that she may not have decision-making capacity

Endoscopic treatment may be performed without further action

Her sister must sign the consent form

Her decision to have an endoscopy is not voluntary

A 67-year-old man is brought to the emergency department because of severe dyspnea and orthopnea for 6 hours. He has a history of congestive heart disease and an ejection fraction of 40%. The medical history is otherwise unremarkable. He appears confused. At the hospital, his blood pressure is 165/110 mm Hg, the pulse is 135/min, the respirations are 48/min, and the temperature is 36.2°C (97.2°F). Crackles are heard at both lung bases. There is pitting edema from the midtibia to the ankle bilaterally. The patient is intubated and admitted to the critical care unit for mechanical ventilation and treatment. Intravenous morphine, diuretics, and nitroglycerine are initiated. Which of the following is the most effective method to prevent nosocomial infection in this patient?

Daily oropharynx decontamination with antiseptic agent

Daily urinary catheter irrigation with antimicrobial agent

A 68-year-old man comes to the emergency department because of sudden onset abdominal pain for 6 hours. On a 10-point scale, he rates the pain as a 8 to 9. The abdominal pain is worst in the right upper quadrant. He has atrial fibrillation and hyperlipidemia. His temperature is 38.7° C (101.7°F), pulse is 110/min, and blood pressure is 146/86 mm Hg. The patient appears acutely ill. Physical examination shows a distended abdomen and tenderness to palpation in all quadrants with guarding, but no rebound. Murphy's sign is positive. Right upper quadrant ultrasound shows thickening of the gallbladder wall, sludging in the gallbladder, and pericolic fat stranding. He is admitted for acute cholecystitis and grants permission for cholecystectomy. His wife is his healthcare power of attorney (POA), but she is out of town on a business trip. He is accompanied today by his brother. After induction and anesthesia, the surgeon removes the gallbladder but also finds a portion of the small intestine is necrotic due to a large thromboembolism occluding a branch of the superior mesenteric artery. The treatment is additional surgery with small bowel resection and thromboendarterectomy. Which of the following is the most appropriate next step in management?

Proceed with additional surgery without obtaining consent

Decrease the patient's sedation until he is able to give consent

Contact the patient's healthcare POA to consent

Ask the patient's brother in the waiting room to consent

Close the patient and obtain re-consent for a second operation

A 72-year-old man presents to the emergency department with chest pain and shortness of breath. An EKG demonstrates an ST elevation myocardial infarction, and he is managed appropriately. The patient suffers from multiple comorbidities and was recently hospitalized for a myocardial infarction. The patient has a documented living will, which specifies that he does wish to receive resuscitative measures and blood products but refuses intubation in any circumstance. The patient is stabilized and transferred to the medical floor. On day 2, the patient presents with ventricular fibrillation and a resuscitative effort occurs. He is successfully resuscitated, but his pulmonary parameters warrant intervention and are acutely worsening. The patient's wife, son, and daughter are present and state that the patient should be intubated. The patient's prognosis even with intubation is very poor. Which of the following describes the best course of action?

Do not intubate the patient given his living will

Intubate the patient - the family is representing the patient's most recent and accurate wishes

Consult the hospital ethics committee

Intubate the patient - a patient's next of kin take precedence over a living will

Do not intubate the patient as his prognosis is poor even with intubation

Advance directives — USMLE Lesson

Advance Directives - The Master Plan

Advance Directive: A legal document outlining a patient's wishes for future medical care should they become unable to make decisions. Rooted in the Patient Self-Determination Act (1990).
Key Types:
- Living Will: Specifies desired treatments (e.g., no mechanical ventilation) if terminally ill or in a persistent vegetative state.
- DPOA-HC (Healthcare Proxy): Designates a person to make healthcare decisions upon incapacitation.
- DNR/DNI: Specific medical orders to withhold CPR or intubation.
- POLST: Converts patient wishes into actionable medical orders for the seriously ill.

Comparison of Advance Directives

⭐ If a patient has both a living will and a healthcare proxy (DPOA-HC), the proxy's decisions generally take precedence, as they can interpret the patient's wishes in the current specific clinical context.

Will vs. Proxy - Paper Power

Advance directives are legal documents for when a patient loses decision-making capacity-a clinical determination distinct from legal competence.

Feature	Living Will (Instructional Directive)	DPOA-HC (Proxy Directive)
What it is	Specifies desired or refused treatments (e.g., mechanical ventilation, tube feeding).	Appoints a surrogate decision-maker (health care proxy) to act for the patient.
Activation	Upon loss of capacity AND presence of a qualifying condition (e.g., terminal illness).	Activates simply when the patient loses decision-making capacity.
Flexibility	Inflexible; only applies to situations explicitly written and can be difficult to interpret.	Highly flexible; the proxy can interpret the patient's wishes for unforeseen circumstances.

⭐ In the absence of an advance directive, states provide a legal hierarchy for the next of kin to act as a surrogate, typically: spouse → adult children → parents.

Medical Orders - The Action Plan

Code Status Orders: Specific medical directives for immediate, life-sustaining interventions.
- DNR (Do Not Resuscitate): Prohibits cardiopulmonary resuscitation (CPR) if a patient's heart or breathing stops.
- DNI (Do Not Intubate): Prohibits the insertion of an endotracheal tube.
POLST (Physician Orders for Life-Sustaining Treatment): A portable medical order for patients who are seriously ill or frail. It translates a patient's end-of-life wishes into actionable medical commands.
- Portability: Valid and honored across different healthcare settings (e.g., home, nursing facility, hospital).
- Actionable: Unlike a traditional advance directive, a POLST is a direct medical order.

POLST form for CPR, medical interventions, and nutrition

⭐ A POLST is for current treatment plans for seriously ill patients, whereas a living will is for future, hypothetical scenarios and is not a medical order.

Capacity & Surrogates - Who Decides?

Decision-Making Capacity: A clinical determination required for informed consent. It is task-specific and can fluctuate. Assessed using:
- 📌 Mnemonic: CURVES
  - Communicate a choice
  - Understand relevant information
  - Reason about treatment options
  - Value the consequences
  - Emergency (not) - capacity is assumed unless challenged.
Surrogate Hierarchy: If no DPOA-HC is designated, the following are approached in order:
- 1. Spouse
- 1. Adult Child (majority consensus)
- 1. Parent
- 1. Adult Sibling

⭐ High-Yield: Capacity is a clinical finding assessed by a physician, while competence is a legal state determined by a judge. A patient can lack capacity for one decision without being legally incompetent overall.

High‑Yield Points - ⚡ Biggest Takeaways

Advance directives are legal documents guiding future medical care if a patient loses decision-making capacity.

A living will outlines specific treatment preferences, while a healthcare proxy (or durable power of attorney) designates a surrogate decision-maker.

Directives must be created when the patient is competent.

A competent patient can revoke or change a directive at any time.

The Patient Self-Determination Act requires institutions to inquire about and uphold advance directives.

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