Legal and ethical issues in dementia care US Medical PG Practice Questions and MCQs
Practice US Medical PG questions for Legal and ethical issues in dementia care. These multiple choice questions (MCQs) cover important concepts and help you prepare for your exams.
Legal and ethical issues in dementia care US Medical PG Question 1: A 33-year-old man is brought by ambulance to the emergency room after being a passenger in a motor vehicle accident. An empty bottle of whiskey was found in his front seat, and the patient admits to having been drinking all night. He has multiple lacerations and bruising on his face and scalp and a supportive cervical collar is placed. He is endorsing a significant headache and starts vomiting in the emergency room. His vitals, however, are stable, and he is transported to the CT scanner. While there, he states that he does not want to have a CT scan and asks to be released. What is the most appropriate course of action?
- A. Have the patient fill the appropriate forms and discharge against medical advice
- B. Explain to him that he is intoxicated and cannot make health care decisions, continue as planned (Correct Answer)
- C. Release the patient as requested
- D. Agree to not do the CT scan
- E. Call security
Legal and ethical issues in dementia care Explanation: ***Explain to him that he is intoxicated and cannot make health care decisions, continue as planned***
- The patient's **intoxication** (empty whiskey bottle, admitted drinking all night) and **head injury symptoms** (headache, vomiting after MVA) suggest he lacks the capacity to make informed medical decisions.
- When a patient lacks capacity, the medical team has an ethical and legal obligation to act in their **best interest**, which includes performing necessary diagnostic tests like a CT scan to rule out serious intracranial injuries.
*Have the patient fill the appropriate forms and discharge against medical advice*
- Discharging a patient against medical advice requires they have the **full capacity** to understand the risks and benefits of their decision, which is compromised by intoxication and head trauma.
- Doing so without ensuring capacity places the patient at significant risk and could have **legal implications** for the healthcare provider and institution.
*Release the patient as requested*
- Releasing an intoxicated patient with a potential **head injury** into the community is medically negligent and highly dangerous given the risk of worsening neurological status.
- Such an action disregards the principle of **beneficence** and the duty to prevent harm, especially when capacity is in question.
*Agree to not do the CT scan*
- Refusing a necessary diagnostic test like a **CT scan** for a patient with head trauma and altered mental status (due to intoxication) can lead to missed diagnoses of life-threatening conditions like intracranial hemorrhage.
- This decision would allow the patient to leave without proper assessment, potentially jeopardizing their life and violating the standard of care to **stabilize** and **diagnose**.
*Call security*
- While security might be needed if the patient becomes disruptive or aggressive, simply calling security without attempting to explain the situation or assess capacity doesn't address the primary medical and ethical dilemma.
- The immediate priority is to ensure the patient's well-being and assess their cognitive ability to make choices, with security being a secondary measure for **safety** if necessary.
Legal and ethical issues in dementia care US Medical PG Question 2: An 82-year-old woman is brought to the physician by her nephew, who lives with her because she has a pessimistic attitude and has displayed overall distrust of her nephew for 1 year. She frequently argues with her nephew and embarrasses him in front of his friends. She had a Colles’ fracture 2 months ago and has had hypertension for 18 years. Her medications include hydrochlorothiazide and nortriptyline. She has a quantity of each leftover since her previous visit 2 months ago and has not requested new prescriptions, which she would need if she were taking them as prescribed. She appears untidy. Her blood pressure is 155/98 mm Hg. She mumbles in response to questions, and her nephew insists on being at her side during the entire visit because she cannot express herself clearly. She has a sore on her ischial tuberosity and bruises around her ankles. Which of the following is the most appropriate action in patient care?
- A. Emphasizing compliance with medication and follow-up in 1 month
- B. Discussing advance directives
- C. Referral for hospice care
- D. Referral to a psychiatrist
- E. Reporting possible elder abuse by phone (Correct Answer)
Legal and ethical issues in dementia care Explanation: ***Reporting possible elder abuse by phone***
- The patient exhibits several red flags for **elder abuse**, including **neglect** (untidy appearance, non-adherence to medication, unaddressed sore), **physical abuse** (bruises around ankles, Colles' fracture, given her age and potential for falls), and possible **financial or emotional abuse** (nephew's over-involvement, patient's distrust and pessimistic attitude, and the nephew insisting on being at her side).
- Given the multiple signs and the immediate safety concerns, reporting to the appropriate **protective services** (e.g., Adult Protective Services) is the most urgent and appropriate initial step to ensure the patient's safety and well-being.
*Emphasizing compliance with medication and follow-up in 1 month*
- While important for chronic conditions, this action does not address the immediate and potentially life-threatening issues of elder abuse and neglect.
- Addressing medication non-adherence alone, without investigating the underlying causes or ensuring the patient's safety, is insufficient and potentially delays critical intervention.
*Discussing advance directives*
- **Advance directives** are important for end-of-life planning but are not the priority when there are suspicious signs of ongoing abuse and neglect affecting the patient's immediate safety and basic care.
- The patient's inability to express herself clearly, as stated by the nephew, further suggests she may not be capable of making informed decisions regarding advance directives at this time.
*Referral for hospice care*
- Hospice care is appropriate for patients with a **terminal illness** and a life expectancy of six months or less, which is not indicated by the information provided.
- While the patient is elderly and appears unwell, there's no evidence to suggest she is terminally ill, making hospice an inappropriate immediate action.
*Referral to a psychiatrist*
- While the patient's pessimistic attitude and distrust could warrant a psychiatric evaluation, the more immediate concern is her safety and well-being due to potential abuse and neglect.
- A psychiatric referral may be appropriate *after* the abuse concerns are addressed and the patient's safety is ensured, but it is not the most appropriate first step.
Legal and ethical issues in dementia care US Medical PG Question 3: A 32-year-old man visits his primary care physician for a routine health maintenance examination. During the examination, he expresses concerns about not wanting to become a father. He has been sexually active and monogamous with his wife for the past 5 years, and they inconsistently use condoms for contraception. He tells the physician that he would like to undergo vasectomy. His wife is also a patient under the care of the physician and during her last appointment, she expressed concerns over being prescribed any drugs that could affect her fertility because she would like to conceive soon. Which of the following is the most appropriate action by the physician regarding this patient's wish to undergo vasectomy?
- A. Explain the procedure's benefits, alternatives, and potential complications (Correct Answer)
- B. Refer the patient to a psychotherapist to discuss his reluctance to have children
- C. Discourage the patient from undergoing the procedure because his wife wants children
- D. Insist that the patient returns with his wife to discuss the risks and benefits of the procedure together
- E. Call the patient's wife to obtain her consent for the procedure
Legal and ethical issues in dementia care Explanation: ***Explain the procedure's benefits, alternatives, and potential complications***
- The physician's primary ethical obligation is to the individual patient, ensuring informed consent for any medical procedure. Providing comprehensive information about **vasectomy benefits, alternatives, and risks** allows the patient to make an autonomous decision.
- While patient-physician confidentiality generally prohibits disclosing specific details of one spouse's medical history to the other, the general knowledge that his wife desires children creates an important backdrop for the discussion. It is the patient's responsibility to consider this and convey this information to his wife.
*Refer the patient to a psychotherapist to discuss his reluctance to have children*
- It is **not appropriate** to assume the patient has a psychological issue solely based on his desire for a vasectomy, even with his wife's conflicting wishes. This action could be seen as judgmental and dismissive of the patient's autonomy.
- A patient's preference for sterilization, even if contrary to a partner's desires, does not inherently indicate a need for psychiatric evaluation unless there are other concerning psychological symptoms.
*Discourage the patient from undergoing the procedure because his wife wants children*
- **Discouraging** the patient based on his wife's wishes infringes upon the patient's **autonomy and reproductive rights**. The physician's role is to provide information and support the patient's informed decisions, not to act as a relationship counselor or impose personal values.
- Medical decisions, especially concerning fertility, are deeply personal, and a physician should not pressure a patient into a decision they do not want based on a partner's separate, yet relevant, wishes.
*Insist that the patient returns with his wife to discuss the risks and benefits of the procedure together*
- While open communication between spouses about reproductive decisions is beneficial, **insisting** on the wife's presence for the consultation undermines the patient's **confidentiality and individual autonomy**. The patient has the right to make medical decisions independently.
- The physician should encourage the patient to discuss this with his wife, but it is ultimately the patient's decision whether to involve her in the consultation for his procedure.
*Call the patient's wife to obtain her consent for the procedure*
- This action would be a **breach of patient confidentiality**. The physician cannot disclose information about the patient's decision or medical discussions with a third party, even a spouse, without the patient's explicit consent.
- A spouse's consent is **not legally or ethically required** for an individual to undergo a vasectomy in most jurisdictions, as it is a decision pertaining to the individual's body and reproductive rights.
Legal and ethical issues in dementia care US Medical PG Question 4: 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?
- A. Withdraw the life support since the patient’s chances of recovery are very low
- B. Contact other family members to get their input for the patient
- C. Act according to the patient’s living will
- D. The durable medical power of attorney’s decision should be followed. (Correct Answer)
- E. Follow the daughter’s decision for the patient
Legal and ethical issues in dementia care Explanation: ***The durable medical power of attorney's decision should be followed***
- The patient designated his friend as his **durable power of attorney for healthcare (DPOA)**, giving him legal authority to make medical decisions when the patient cannot communicate.
- While the living will states life support "until full recovery," the patient has **terminal stage colon cancer** - full recovery is **medically impossible**. The living will's condition cannot be fulfilled.
- When advance directive language is ambiguous or cannot be applied to actual clinical circumstances, the **DPOA's interpretive authority** is essential. The DPOA is expected to apply the patient's values to the real situation.
- The DPOA states the patient would not want to be on life support - this reflects the patient's **values and wishes** as understood by his chosen decision-maker, applied to the actual terminal situation.
- This honors both **patient autonomy** (through his chosen proxy) and the reality that advance directives cannot anticipate every clinical scenario.
*Act according to the patient's living will*
- While a living will expresses patient wishes, it states life support should continue "**until full recovery**" - but the patient has terminal cancer with no possibility of recovery.
- Literal adherence to an advance directive whose conditions are **medically impossible** does not serve the patient's true interests or autonomy.
- Living wills and DPOAs work **together** - the DPOA interprets and applies the living will to actual circumstances, especially when literal application is impossible or the situation wasn't anticipated.
*Withdraw the life support since the patient's chances of recovery are very low*
- While this may align with the DPOA's interpretation of the patient's wishes, unilateral physician decision-making without following the proper **decision-making hierarchy** is inappropriate.
- The physician should work **with the DPOA** rather than make independent decisions about life support withdrawal.
*Contact other family members to get their input for the patient*
- The patient **legally designated** his friend as DPOA, indicating his trust in this person's judgment over family members.
- While family input can be valuable, seeking additional opinions when there is a **legally appointed decision-maker** undermines the patient's explicit choice.
- The daughter has no legal standing to override the DPOA's decisions.
*Follow the daughter's decision for the patient*
- The daughter was **not designated** as the healthcare decision-maker; the friend was explicitly chosen as DPOA.
- Following the daughter's wishes would **violate** the patient's autonomous choice of decision-maker.
- Family relationship alone does not override a formal DPOA designation.
Legal and ethical issues in dementia care US Medical PG Question 5: 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
Legal and ethical issues in dementia care 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.
Legal and ethical issues in dementia care US Medical PG Question 6: A 43-year-old male is transferred from an outside hospital to the neurologic intensive care unit for management of a traumatic brain injury after suffering a 30-foot fall from a roof-top. He now lacks decision-making capacity but does not fulfill the criteria for brain-death. The patient does not have a living will and did not name a specific surrogate decision-maker or durable power of attorney. Which of the following would be the most appropriate person to name as a surrogate decision maker for this patient?
- A. The patient's 67-year-old mother
- B. The patient's 22-year-old daughter (Correct Answer)
- C. The patient's girlfriend of 12 years
- D. The patient's older brother
- E. The patient's younger sister
Legal and ethical issues in dementia care Explanation: **The patient's 22-year-old daughter**
- Most jurisdictions prioritize next of kin in a specific order, typically **spouse**, adult children, parents, and then siblings if no advanced directives exist.
- An **adult child** ranks higher in most default surrogate decision-making hierarchies than parents, siblings, or unmarried partners.
*The patient's 67-year-old mother*
- While a close family member, a **parent** is typically lower on the hierarchy of surrogate decision-makers than an adult child.
- The goal is often to find someone who best understands the patient's wishes, and adult children are generally assumed to have this insight more than parents in many legal frameworks.
*The patient's girlfriend of 12 years*
- An **unmarried partner or girlfriend**, regardless of relationship length, typically holds no legal standing as a surrogate decision-maker unless explicitly named in an advanced directive.
- Legal frameworks prioritize **blood relatives** or legally recognized unions (marriage) when no formal documentation exists.
*The patient's older brother*
- A **sibling** is usually further down the hierarchy of surrogate decision-makers after adult children and parents.
- While a family member, they would not be prioritized over a child in the absence of other directives.
*The patient's younger sister*
- Similar to the brother, a **sibling** is generally lower on the hierarchy than an adult child or parent.
- Family relationships are important, but legal protocols follow specific orders of precedence.
Legal and ethical issues in dementia care US Medical PG Question 7: A 75-year-old nursing home resident presents with multiple unexplained bruises in various stages of healing on the upper arms and inner thighs. The patient appears withdrawn and anxious when staff members enter the room. Which of the following is the most appropriate next step?
- A. Request psychiatric consultation
- B. Prescribe anti-anxiety medication
- C. Schedule follow-up in one week
- D. Report suspected abuse to adult protective services (Correct Answer)
Legal and ethical issues in dementia care Explanation: ***Report suspected abuse to adult protective services***
- Multiple unexplained bruises in various stages of healing, particularly on the **upper arms and inner thighs**, are highly suspicious for **physical abuse**, especially in an elderly, vulnerable patient.
- The patient's withdrawn and anxious behavior around staff further supports a suspicion of abuse, necessitating immediate reporting to Adult Protective Services as a **mandated reporter**.
*Request psychiatric consultation*
- While the patient's anxiety and withdrawal might warrant psychiatric evaluation, addressing the potential **physical abuse** takes immediate precedence due to safety concerns.
- A psychiatric consultation alone would not address the root cause of potential harm or ensure the patient's safety.
*Prescribe anti-anxiety medication*
- Administering anti-anxiety medication would only mask the symptoms (anxiety) without investigating or resolving the underlying cause of distress, which appears to be related to **potential abuse**.
- This approach could delay identification of a serious safety issue, potentially putting the patient at further risk.
*Schedule follow-up in one week*
- Delaying action for a week is inappropriate given the strong suspicion of ongoing **abuse** and the patient's vulnerability.
- Waiting could allow further harm to occur and does not fulfill the ethical and legal obligations of a healthcare professional in cases of suspected abuse.
Legal and ethical issues in dementia care US Medical PG Question 8: A 69-year-old woman with acute myeloid leukemia comes to the physician to discuss future treatment plans. She expresses interest in learning more about an experimental therapy being offered for her condition. After the physician explains the mechanism of the drug and describes the risks and benefits, the patient then states that she is not ready to die. When the physician asks her what her understanding of the therapy is, she responds "I don't remember the details, but I just know that I definitely want to try it, because I don't want to die." Which of the following ethical principles is compromised in this physician's interaction with the patient?
- A. Patient competence
- B. Patient autonomy
- C. Decision-making capacity (Correct Answer)
- D. Information disclosure
- E. Therapeutic privilege
Legal and ethical issues in dementia care Explanation: ***Decision-making capacity***
- This refers to a patient's ability to **understand information relevant to a medical decision**, appreciate their situation, reason through options, and communicate a choice. The patient's statement indicates a lack of understanding of the details of the complex treatment, despite being explained.
- While she expresses a choice, her inability to recall details suggests she cannot adequately **weigh risks and benefits**, which is central to capacity.
*Patient competence*
- **Competence is a legal determination** made by a court, not by a physician in a clinical setting.
- Physicians assess **decision-making capacity**, which is a clinical judgment, whereas legal competence has broader implications.
*Patient autonomy*
- **Autonomy is the right of a patient to make their own choices** about their medical care. While the patient is attempting to exercise a choice, the issue here is whether she is able to make an adequately informed choice.
- For autonomy to be truly upheld, the patient must have the **capacity to make an informed decision**, which is compromised by her stated lack of understanding.
*Information disclosure*
- The physician *did* disclose information about the drug's mechanism, risks, and benefits, indicating that the act of disclosure itself was performed.
- The problem is not that information was withheld, but that the patient **did not retain or understand the disclosed information** sufficiently.
*Therapeutic privilege*
- **Therapeutic privilege** is when a physician withholds information from a patient if they believe the disclosure would cause significant harm.
- In this scenario, the physician *did* explain the treatment, so information was not withheld under privilege.
Legal and ethical issues in dementia care US Medical PG Question 9: A 23-year-old woman presents to the emergency department with acute alcohol intoxication. Her blood alcohol level is 280 mg/dL. She becomes increasingly agitated and attempts to leave against medical advice. Which of the following determines her capacity to refuse treatment?
- A. Age of the patient
- B. Family's wishes
- C. Blood alcohol level
- D. Understanding of risks and benefits (Correct Answer)
Legal and ethical issues in dementia care Explanation: ***Understanding of risks and benefits***
- A patient's capacity to refuse treatment is primarily determined by their **ability to understand the nature of their condition**, the proposed treatment, and the **potential risks and benefits** of both accepting and refusing treatment.
- Even with intoxication, if a patient can demonstrate this understanding, they technically have the capacity to make decisions, though the intoxication itself often impairs this ability.
- Capacity assessment includes four key elements: understanding information, appreciating how it applies to their situation, reasoning through options, and communicating a choice.
*Age of the patient*
- While age is a factor in pediatric care (requiring parental consent for minors), for adults, it does not solely determine capacity; an adult of any age can be deemed to lack capacity for various reasons.
- The patient's age (23 years old) indicates she is legally an adult, but it does not automatically confer or deny treatment capacity, which is assessed based on mental status.
*Family's wishes*
- Family wishes are important for patients who **lack decision-making capacity** and have no advance directives, but they do not override the decisions of a fully capacitated patient.
- In situations where capacity is questionable, family input might be considered, but the direct assessment of the patient's understanding remains paramount.
*Blood alcohol level*
- A high blood alcohol level strongly suggests impaired judgment and cognitive function, making it a red flag for potential lack of capacity, but it is not a direct measure of capacity itself.
- Some individuals may maintain a degree of understanding even with high levels, so a direct assessment of their comprehension is still necessary, not just assuming based on the level alone.
Legal and ethical issues in dementia care US Medical PG Question 10: A 10-year-old boy is brought into your clinic by his mother for sunburns that have not been healing. The mother states that he easily gets sunburned. The mother admits she gave birth to him at home and has never taken him to see a doctor. The patient walks with a wide stance gait and appears unstable on his feet. He has an extensive erythematous, scaling, hyperkeratotic rash on his face, neck, arms and legs. After extensive workup, the patient is found to have a genetic disorder that results in defective absorption of an important vitamin. Which of the following is likely to be low if measured?
- A. Vitamin K
- B. Niacin (Correct Answer)
- C. Folate
- D. Vitamin A
- E. Vitamin B12
Legal and ethical issues in dementia care Explanation: ***Niacin***
- The constellation of **sunburns that don't heal**, a **wide-stanced unstable gait**, and an **erythematous, scaling, hyperkeratotic rash** (consistent with dermatitis) strongly suggests **pellagra**.
- Pellagra is caused by a deficiency of **niacin (Vitamin B3)**, which is characterized by the "3 Ds": **dermatitis**, **diarrhea**, and **dementia (or neurological symptoms like ataxia)**.
*Vitamin K*
- Deficiency typically leads to **bleeding disorders** due to impaired coagulation, which is not indicated by the patient's symptoms.
- While newborns often receive a **vitamin K shot**, his current symptoms are unrelated to its deficiency.
*Folate*
- Folate deficiency primarily causes **megaloblastic anemia** and can lead to **neural tube defects** in developing fetuses.
- It does not explain the characteristic dermatological and neurological symptoms described.
*Vitamin A*
- Vitamin A deficiency is known to cause **night blindness** and **xerophthalmia** (dry eyes), and impaired immune function.
- While it plays a role in skin health, the specific rash and gait abnormalities point away from primary vitamin A deficiency.
*Vitamin B12*
- Deficiency leads to **megaloblastic anemia** with **neurological symptoms** such as peripheral neuropathy, but the dermatological manifestations (scaling, hyperkeratotic rash) and unhealing sunburn are not typical.
- The gait could be linked to neurological symptoms, but the overall presentation is better explained by niacin deficiency.
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