Measuring consent quality US Medical PG Practice Questions and MCQs
Practice US Medical PG questions for Measuring consent quality. These multiple choice questions (MCQs) cover important concepts and help you prepare for your exams.
Measuring consent quality US Medical PG Question 1: A research team develops a new monoclonal antibody checkpoint inhibitor for advanced melanoma that has shown promise in animal studies as well as high efficacy and low toxicity in early phase human clinical trials. The research team would now like to compare this drug to existing standard of care immunotherapy for advanced melanoma. The research team decides to conduct a non-randomized study where the novel drug will be offered to patients who are deemed to be at risk for toxicity with the current standard of care immunotherapy, while patients without such risk factors will receive the standard treatment. Which of the following best describes the level of evidence that this study can offer?
- A. Level 1
- B. Level 3 (Correct Answer)
- C. Level 5
- D. Level 4
- E. Level 2
Measuring consent quality Explanation: ***Level 3***
- A **non-randomized controlled trial** like the one described, where patient assignment to treatment groups is based on specific characteristics (risk of toxicity), falls into Level 3 evidence.
- This level typically includes **non-randomized controlled trials** and **well-designed cohort studies** with comparison groups, which are prone to selection bias and confounding.
- The study compares two treatments but lacks randomization, making it Level 3 evidence.
*Level 1*
- Level 1 evidence is the **highest level of evidence**, derived from **systematic reviews and meta-analyses** of multiple well-designed randomized controlled trials or large, high-quality randomized controlled trials.
- The described study is explicitly stated as non-randomized, ruling out Level 1.
*Level 2*
- Level 2 evidence involves at least one **well-designed randomized controlled trial** (RCT) or **systematic reviews** of randomized trials.
- The current study is *non-randomized*, which means it cannot be classified as Level 2 evidence, as randomization is a key criterion for this level.
*Level 4*
- Level 4 evidence includes **case series**, **case-control studies**, and **poorly designed cohort or case-control studies**.
- While the study is non-randomized, it is a controlled comparative trial rather than a case series or retrospective case-control study, placing it at Level 3.
*Level 5*
- Level 5 evidence is the **lowest level of evidence**, typically consisting of **expert opinion** without explicit critical appraisal, or based on physiology, bench research, or animal studies.
- While the drug was initially tested in animal studies, the current human comparative study offers a higher level of evidence than expert opinion or preclinical data.
Measuring consent quality 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)
Measuring consent quality 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.
Measuring consent quality US Medical PG Question 3: A 19-year-old woman is diagnosed with metastatic Ewing sarcoma. She has undergone multiple treatments without improvement. She decides to stop treatment and pursue only palliative care. She is of sound mind and has weighed the benefits and risks of this decision. The patient’s mother objects and insists that treatments be continued. What should be done?
- A. Try to seek additional experimental treatments that are promising.
- B. Follow the wishes of the patient’s mother as she has decision making power for the patient.
- C. Continue treatments until the patient has a psychiatric evaluation.
- D. Continue treatment because otherwise, the patient will die.
- E. Halt treatments and begin palliative care. (Correct Answer)
Measuring consent quality Explanation: ***Halt treatments and begin palliative care.***
- An adult patient of **sound mind** has the right to refuse medical treatment, even if that refusal may lead to death. This principle is a cornerstone of **patient autonomy**.
- The patient has clearly expressed her wishes after weighing the benefits and risks, making her decision legally and ethically binding.
*Try to seek additional experimental treatments that are promising.*
- While seeking additional treatments might be an option if the patient desired it, forcing such treatments against her will violates her **autonomy** and right to self-determination.
- The case states the patient has decided to stop treatment, making further treatment exploration against her expressed wishes.
*Follow the wishes of the patient’s mother as she has decision making power for the patient.*
- The patient is 19 years old, making her a **legal adult**, and therefore her mother does not have decision-making power over her medical care.
- The patient's mother's wishes, while understandable from an emotional perspective, do not supersede the **competent adult patient's** right to make her own medical decisions.
*Continue treatments until the patient has a psychiatric evaluation.*
- The patient is described as being of "sound mind" and having "weighed the benefits and risks," indicating she is making an informed decision.
- Requesting a psychiatric evaluation without clear evidence of impaired mental capacity would be a disrespectful and unethical attempt to override her **autonomously made decision**.
*Continue treatment because otherwise, the patient will die.*
- While it is true that stopping treatment will likely lead to death, a **competent adult patient** has the right to refuse life-sustaining treatment.
- The patient's right to **autonomy** and control over her own body takes precedence over the desire of others (including medical professionals or family) to prolong life against her will.
Measuring consent quality US Medical PG Question 4: A 57-year-old man presents to his oncologist to discuss management of small cell lung cancer. The patient is a lifelong smoker and was diagnosed with cancer 1 week ago. The patient states that the cancer was his fault for smoking and that there is "no hope now." He seems disinterested in discussing the treatment options and making a plan for treatment and followup. The patient says "he does not want any treatment" for his condition. Which of the following is the most appropriate response from the physician?
- A. "You seem upset at the news of this diagnosis. I want you to go home and discuss this with your loved ones and come back when you feel ready to make a plan together for your care."
- B. "It must be tough having received this diagnosis; however, new cancer therapies show increased efficacy and excellent outcomes."
- C. "It must be very challenging having received this diagnosis. I want to work with you to create a plan." (Correct Answer)
- D. "We are going to need to treat your lung cancer. I am here to help you throughout the process."
- E. "I respect your decision and we will not administer any treatment. Let me know if I can help in any way."
Measuring consent quality Explanation: ***"It must be very challenging having received this diagnosis. I want to work with you to create a plan."***
- This response **acknowledges the patient's emotional distress** and feelings of guilt and hopelessness, which is crucial for building rapport and trust.
- It also gently **re-engages the patient** by offering a collaborative approach to treatment, demonstrating the physician's commitment to supporting him through the process.
*"You seem upset at the news of this diagnosis. I want you to go home and discuss this with your loved ones and come back when you feel ready to make a plan together for your care."*
- While acknowledging distress, sending the patient home without further engagement **delays urgent care** for small cell lung cancer, which is aggressive.
- This response might be perceived as dismissive of his immediate feelings and can **exacerbate his sense of hopelessness** and isolation.
*"It must be tough having received this diagnosis; however, new cancer therapies show increased efficacy and excellent outcomes."*
- This statement moves too quickly to treatment efficacy without adequately addressing the patient's current **emotional state and fatalism**.
- While factual, it **lacks empathy** for his personal feelings of blame and hopelessness, potentially making him feel unheard.
*"We are going to need to treat your lung cancer. I am here to help you throughout the process."*
- This response is **too directive and authoritarian**, which can alienate a patient who is already feeling guilty and resistant to treatment.
- It fails to acknowledge his stated feelings of "no hope now" or his disinterest in treatment, which are critical to address before discussing the necessity of treatment.
*"I respect your decision and we will not administer any treatment. Let me know if I can help in any way."*
- While respecting patient autonomy is vital, immediately accepting a patient's decision to refuse treatment without exploring the underlying reasons (e.g., guilt, hopelessness, lack of information) is **premature and potentially harmful**.
- The physician has a responsibility to ensure the patient is making an informed decision, especially for a rapidly progressing condition like small cell lung cancer.
Measuring consent quality US Medical PG Question 5: A 16-year-old female presents to her pediatrician's office requesting to be started on an oral contraceptive pill. She has no significant past medical history and is not currently taking any medications. The physician is a devout member of the Roman Catholic church and is strongly opposed to the use of any type of artificial contraception. Which of the following is the most appropriate response to this patient's request?
- A. Suggest that the patient remain abstinent or, if necessary, use an alternative means of birth control
- B. Explain that he will refer the patient to one of his partners who can fulfill this request (Correct Answer)
- C. Refuse to prescribe the oral contraceptive
- D. Tell the patient that he is unable to prescribe this medication without parental consent
- E. The physician is obligated to prescribe the oral contraceptives regardless of his personal beliefs
Measuring consent quality Explanation: ***Explain that he will refer the patient to one of his partners who can fulfill this request***
- Physicians have a right to **conscientious objection** based on personal beliefs, but they also have an ethical obligation to ensure that patients receive appropriate medical care.
- Referring the patient to another qualified provider for the requested service fulfills both the physician's right to object and the patient's right to care, without imposing the physician's personal beliefs on the patient.
*Suggest that the patient remain abstinent or, if necessary, use an alternative means of birth control*
- While abstinence is a valid choice, suggesting it without offering the requested medical service is imposing the physician's personal beliefs on the patient, which is **unethical** in this context.
- Recommending only "alternative means" without directly addressing the patient's specific request for oral contraceptives does not adequately address her healthcare needs or autonomy.
*Refuse to prescribe the oral contraceptive*
- An outright refusal without providing an alternative option or referral **violates the ethical principle** of beneficence and the patient's right to access medical care.
- This action could be seen as abandoning the patient and is not consistent with professional medical ethics for handling conscientious objections.
*Tell the patient that he is unable to prescribe this medication without parental consent*
- In many jurisdictions, minors are legally allowed to obtain contraception **without parental consent** due to privacy and public health considerations (e.g., prevention of STIs and unintended pregnancies).
- This statement may be **legally incorrect** and serves as an excuse to avoid providing the requested service, rather than addressing the ethical dilemma of conscientious objection appropriately.
*The physician is obligated to prescribe the oral contraceptives regardless of his personal beliefs*
- While physicians have an obligation to provide care, they are generally **not obligated to perform services that violate their deeply held moral or religious beliefs**, provided they ensure the patient can access the service elsewhere.
- This option incorrectly states that personal beliefs must always be overridden for every medical service, ignoring the principle of conscientious objection while ensuring patient access to care.
Measuring consent quality US Medical PG Question 6: 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)
Measuring consent quality 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.
Measuring consent quality US Medical PG Question 7: A 32-year-old male asks his physician for information regarding a vasectomy. On further questioning, you learn that he and his wife have just had their second child and he asserts that they no longer wish to have additional pregnancies. You ask him if he has discussed a vasectomy with his wife to which he replies, "Well, not yet, but I'm sure she'll agree." What is the next appropriate step prior to scheduling the patient's vasectomy?
- A. Insist that the patient first discuss this procedure with his wife
- B. Telephone the patient's wife to inform her of the plan
- C. Refuse to perform the vasectomy
- D. Explain the risks and benefits of the procedure and request signed consent from the patient and his wife
- E. Explain the risks and benefits of the procedure and request signed consent from the patient (Correct Answer)
Measuring consent quality Explanation: ***Explain the risks and benefits of the procedure and request signed consent from the patient***
- A patient has the **right to make autonomous decisions** about their own medical care, including reproductive choices, regardless of their marital status or spousal approval.
- The physician's role is to ensure the patient is fully informed and provides **voluntary, uncoerced consent** after understanding the risks, benefits, and alternatives of the procedure.
*Insist that the patient first discuss this procedure with his wife*
- This option would be a **violation of patient autonomy** and confidentiality, as a married person has the right to make independent medical decisions.
- Requiring spousal consent for a procedure performed solely on one individual is not ethically or legally mandated and could be considered discriminatory.
*Telephone the patient's wife to inform her of the plan*
- This action would be a **breach of patient confidentiality**, as the patient's medical information, including his intent to have a vasectomy, cannot be shared with a third party, even a spouse, without explicit permission.
- Informing the wife without the husband's consent also undermines the patient's autonomy and right to privacy regarding his healthcare decisions.
*Refuse to perform the vasectomy*
- Refusing to perform the procedure simply because the patient has not discussed it with his wife would be **unethical and inconsistent with medical professionalism**, assuming the patient is competent and fully informed.
- A physician should not deny medically appropriate care based on a patient's marital dynamics or the presumed wishes of a spouse, as long as the patient's consent is valid.
*Explain the risks and benefits of the procedure and request signed consent from the patient and his wife*
- While it is advisable for a patient to discuss major life decisions with their spouse, requiring **spousal consent for a patient's own medical procedure** is not legally or ethically mandated for competent adults.
- Obtaining consent from both individuals is typically reserved for procedures affecting both parties directly or for those involving a surrogate decision-maker, not for an autonomous adult's personal medical choice.
Measuring consent quality US Medical PG Question 8: A 28-year-old woman is brought to the emergency department after being resuscitated in the field. Her husband is with her and recalls seeing pills beside her when he was in the bathroom. He reveals she has a past medical history of depression and was recently given a prescription for smoking cessation. On physical exam, you notice a right-sided scalp hematoma and a deep laceration to her tongue. She has a poor EEG waveform indicating limited to no cerebral blood flow and failed both her apnea test and reflexes. She is found to be in a persistent vegetative state, and the health care team starts to initiate the end of life discussion. The husband states that the patient had no advance directives other than to have told her husband she did not want to be kept alive with machines. The parents want all heroic measures to be taken. Which of the following is the most accurate statement with regards to this situation?
- A. The physician may be appointed as the patient’s health care surrogate and may make end-of-life decisions on her behalf.
- B. The patient’s parents may be appointed as her health care surrogate and may make end-of-life decisions on her behalf.
- C. The patient’s husband may be appointed as her health care surrogate and may make end-of-life decisions on her behalf. (Correct Answer)
- D. An ethics committee must be appointed as the patient’s health care surrogate and may make end-of-life decisions on her behalf.
- E. A court-appointed guardian may be appointed as the patient's health care surrogate and may make end-of-life decisions on her behalf.
Measuring consent quality Explanation: ***The patient’s husband may be appointed as her health care surrogate and may make end-of-life decisions on her behalf.***
- The **hierarchy for healthcare surrogates** typically prioritizes the spouse over parents when there is no advance directive. The husband's recollection of the patient's wishes, although not a formal advance directive, is also relevant.
- State laws generally designate the **spouse as the primary default decision-maker** for incapacitated patients, followed by adult children, parents, and then adult siblings.
*The physician may be appointed as the patient’s health care surrogate and may make end-of-life decisions on her behalf.*
- A physician's role is to provide medical care and guidance, not to act as a **healthcare surrogate** due to potential conflicts of interest.
- Appointing the treating physician as a surrogate undermines the principles of **patient autonomy** and impartial decision-making.
*The patient’s parents may be appointed as her health care surrogate and may make end-of-life decisions on her behalf.*
- While parents are part of the surrogate hierarchy, they are generally ranked below the **spouse** in most jurisdictions.
- The parents' desire for "heroic measures" directly conflicts with the patient's stated wish to her husband, potentially leading to decisions not in the patient's best interest or previously expressed values.
*An ethics committee must be appointed as the patient’s health care surrogate and may make end-of-life decisions on her behalf.*
- An ethics committee's role is to provide **guidance and recommendations** in complex cases, mediate disputes, and ensure ethical principles are upheld, not to act as the primary healthcare surrogate.
- A functional healthcare surrogate takes precedence over an ethics committee in making direct treatment decisions.
*A court-appointed guardian may be appointed as the patient's health care surrogate and may make end-of-life decisions on her behalf.*
- A court-appointed guardian is typically sought only if there is **no clear or willing surrogate** from the established hierarchy, or if there is a dispute among family members that cannot be resolved.
- In this scenario, the husband is the legally recognized next of kin and surrogate by default, making court intervention unnecessary at this stage.
Measuring consent quality US Medical PG Question 9: A 32-year-old man is brought to the emergency department by the police for examination. The police have reason to believe he may have swallowed a large number of cocaine-containing capsules during an attempt to smuggle the drug across the border. They request an examination of the patient to determine if this is actually the case. The patient has no history of any serious illnesses and takes no medications. He does not smoke, drinks, or consume any drugs. He appears upset. His vital signs are within normal limits. Despite the pressure by the police, he refuses to undergo any further medical evaluation. Which of the following is the most appropriate next step in the evaluation of this patient?
- A. Examine the patient without his consent
- B. Request a court order from the police
- C. Obtain an abdominal X-ray
- D. Refuse to examine the patient
- E. Explain the risk of internal rupture to the patient (Correct Answer)
Measuring consent quality Explanation: ***Explain the risk of internal rupture to the patient***
- The primary responsibility of the physician is to the **patient's well-being**, not to law enforcement. Before any action, the patient must be fully informed of the **potential life-threatening risks**, such as capsule rupture and overdose, associated with concealing drugs internally, especially if they are asymptomatic.
- This approach respects the patient's **autonomy** while ensuring they understand the gravity of their situation, potentially motivating them to reconsider their refusal for medical evaluation for their own safety.
*Examine the patient without his consent*
- Examining an **adult patient without their consent** is a violation of ethical principles and could constitute **assault and battery**, regardless of police requests or suspected criminal activity.
- The patient's **competence** to refuse care is not questioned, and there is no immediate indication of a medical emergency that would override his refusal, as his vital signs are stable and he is not in distress.
*Request a court order from the police*
- While a court order might compel some medical procedures in specific legal contexts, it generally does not override a competent patient's right to refuse medical care, especially when they are **asymptomatic** and not in immediate danger.
- The physician's immediate ethical duty is to the patient's health and safety, not to facilitate legal processes that could infringe on patient rights without clear medical necessity.
*Obtain an abdominal X-ray*
- An abdominal X-ray is a medical procedure that requires patient consent. Performing it without consent would be a breach of **medical ethics** and patient rights, even if requested by police.
- Although an X-ray could confirm the presence of foreign objects, it should not be performed before **informed consent** is obtained or before the patient understands the potential risks they face due to the suspected objects.
*Refuse to examine the patient*
- While the patient initially refused examination, simply refusing to examine him at all would be negligent as it indicates a failure to address the potential medical emergency presented by suspected internal drug smuggling.
- The physician has a duty to at least **educate the patient** about the severe health risks involved, allowing him to make an informed decision about further medical evaluation.
Measuring consent quality US Medical PG Question 10: 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?
- A. Decrease the patient's sedation until he is able to give consent
- B. Contact the patient's healthcare POA to consent
- C. Proceed with additional surgery without obtaining consent (Correct Answer)
- D. Ask the patient's brother in the waiting room to consent
- E. Close the patient and obtain re-consent for a second operation
Measuring consent quality Explanation: ***Proceed with additional surgery without obtaining consent***
- In an **emergency situation** where immediate intervention is required to save a patient's life or prevent serious harm, and the patient **lacks capacity** to consent, explicit consent for additional necessary procedures is not required. The surgeon can proceed based on the principle of **implied consent** in emergencies.
- The discovery of **necrotic small bowel due to thromboembolism** is a life-threatening condition requiring urgent surgical intervention in an already sedated patient, making it an emergency.
*Decrease the patient's sedation until he is able to give consent*
- Decreasing sedation to obtain consent in this critical situation would cause a **dangerous delay** in treating a life-threatening condition (bowel necrosis) and could lead to worsening outcomes or death.
- The patient is **acutely ill** and likely in a state where he cannot grasp information and make decisions, even with reduced sedation, thus true informed consent would be difficult to obtain quickly.
*Contact the patient's healthcare POA to consent*
- Contacting the POA who is out of town would introduce **significant and potentially fatal delays** in treating a rapidly progressing, life-threatening condition.
- While POAs are crucial for non-emergent decision-making, the **principle of preserving life** takes precedence in an acute emergency when a delay would cause irreversible harm.
*Ask the patient's brother in the waiting room to consent*
- The brother is **not the designated healthcare POA** and there is no indication he has legal authority to make medical decisions for the patient.
- Relying on a non-POA family member for consent in an emergency, when the patient's legally appointed surrogate is known, is generally **not the appropriate first step** unless no other option exists and the brother can confirm the patient's wishes from prior discussions, which is not stated.
*Close the patient and obtain re-consent for a second operation*
- Closing the patient and then re-opening for another surgery would expose the patient to **two separate anesthetic events and surgical procedures**, significantly increasing morbidity and mortality risks compared to continuous surgery.
- This option would also introduce an **unacceptable delay** in addressing the acute bowel necrosis, which requires immediate intervention.
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