A 76-year-old man is brought to the hospital after having a stroke. Head CT is done in the emergency department and shows intracranial hemorrhage. Upon arrival to the ED he is verbally non-responsive and withdraws only to pain. He does not open his eyes. He is transferred to the medical ICU for further management and intubated for airway protection. During his second day in the ICU, his blood pressure is measured as 91/54 mmHg and pulse is 120/min. He is given fluids and antibiotics, but he progresses to renal failure and his mental status deteriorates. The physicians in the ICU ask the patient’s family what his wishes are for end-of-life care. His wife tells the team that she is durable power of attorney for the patient and provides appropriate documentation. She mentions that he did not have a living will, but she believes that he would want care withdrawn in this situation, and therefore asks the team to withdraw care at this point. The patient’s daughter vehemently disagrees and believes it is in the best interest of her father, the patient, to continue all care. Based on this information, what is the best course of action for the physician team?

Listen to the patient’s wife’s wishes and withdraw care

Call other family members and consult them for their opinions

Listen to the patient’s daughter’s wishes and continue all care

Compromise between the wife and daughter and withdraw the fluids and antibiotics but keep the patient intubated

Consult the hospital ethics committee and continue all care until a decision is reached

A 63-year-old woman is brought to the emergency department because of severe abdominal pain and vomiting for 3 hours. She had previous episodes of abdominal pain that lasted for 10–15 minutes and resolved with antacids. She lives with her daughter and grandchildren. She divorced her husband last year. She is alert and oriented. Her temperature is 37.3°C (99.1°F), pulse is 134/min, and blood pressure is 90/70 mm Hg. The abdomen is rigid and diffusely tender. Guarding and rebound tenderness are present. Rectal examination shows a collapsed rectum. Infusion of 0.9% saline is begun and a CT of the abdomen shows intestinal perforation. The surgeon discusses the need for emergent exploratory laparotomy with the patient and she agrees to it. Written informed consent is obtained. While in the holding area awaiting emergent transport to the operating room, she calls for the surgeon and informs him that she no longer wants the surgery. He explains the risks of not performing the surgery to her and she indicates she understands but is adamant about not proceeding with surgery. Which of the following is the most appropriate next step in management?

Consult hospital ethics committee

Obtain consent from the patient's daughter

Obtain consent from the patient's ex-husband

Continue with emergency life-saving surgery

A 35-year-old woman with no significant past medical history is brought in by ambulance after a major motor vehicle collision. Temperature is 97.8 deg F (36.5 deg C), blood pressure is 76/40, pulse is 110/min, and respirations are 12/min. She arouses to painful stimuli and makes incomprehensible sounds, but is unable to answer questions. Her abdomen is distended and diffusely tender to palpation. Bedside ultrasound shows blood in the peritoneal cavity. Her husband rushes to the bedside and states she is a Jehovah’s Witness and will refuse blood products. No documentation of blood refusal is available for the patient. What is the most appropriate next step in management?

In accordance with the husband's wishes, do not transfuse any blood products

Observe and reassess mental status in an hour to see if patient can consent for herself

Attempt to contact the patient’s parents for additional collateral information

Consult the hospital ethics committee

A 43-year-old woman presents to her primary care physician with complaints of mild shortness of breath and right-sided chest pain for three days. She reports that lately she has had a nagging nonproductive cough and low-grade fevers. On examination, her vital signs are: temperature 99.1 deg F (37.3 deg C), blood pressure is 115/70 mmHg, pulse is 91/min, respirations are 17/min, and oxygen saturation 97% on room air. She is well-appearing, with normal work of breathing, and no leg swelling. She is otherwise healthy, with no prior medical or surgical history, currently taking no medications. The attending has a low suspicion for the most concerning diagnosis and would like to exclude it with a very sensitive though non-specific test. Which of the following should this physician order?

Obtain spiral CT chest with IV contrast

Order a lower extremity ultrasound

Obtain ventilation-perfusion scan

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 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?

Understanding of risks and benefits

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

DNR/DNAR orders for USMLE Step 1: High-Yield Patient Safety Lessons

DNR/DNAR Orders - The No-Code Lowdown

DNR/DNAR: "Do Not Resuscitate/Attempt Resuscitation." A physician's order to withhold Cardiopulmonary Resuscitation (CPR), including chest compressions, intubation, and defibrillation.
AND: "Allow Natural Death" is a patient-centered alternative, focusing on comfort.
Advance Directive vs. Physician Order: An advance directive states wishes (e.g., living will). A DNR is a direct, actionable medical order signed by a physician.
Medical Futility: Justifies a DNR when CPR is judged to be ineffective or non-beneficial, preventing unnecessary suffering.

⭐ A DNR order does NOT mean "do not treat." It applies only to CPR. All other comfort and medical treatments (e.g., antibiotics, pain relief) continue.

Legal & Ethical Basis - Whose Choice Is It?

Patient Autonomy: The core principle. A patient with decisional capacity has the right to accept or refuse life-sustaining treatment.
Decisional Capacity: A clinical judgment assessing if a patient can understand, appreciate, reason, and communicate a choice. It is task-specific and can fluctuate.

Advance Directives:
- Living Will: Written instructions for future care.
- Healthcare Proxy: Designated person to make decisions.
- POLST/MOLST: Portable medical orders for seriously ill patients.

⭐ Capacity vs. Competence: "Capacity" is a clinical determination made by a physician at the bedside. "Competence" is a legal state determined by a judge. A clinician assesses for capacity, not competence.

Clinical Implementation - Putting Plans in Place

Communication First:
- Engage in clear dialogue with the patient and/or family.
- Explain precisely what a DNR order withholds: chest compressions, intubation, defibrillation.
- Correct misconceptions: Emphasize this is not a "do not treat" order; all other medical and comfort care continues.
Documentation is Crucial:
- The order must be a signed physician's order, clearly visible in the medical record.
- Portable orders (POLST/MOLST) are vital to honor wishes across different care settings.
Scope & Palliative Care:
- Define the specific scope of the order (e.g., CPR only, or also vasopressors).
- Consult palliative care to manage symptoms and align care with patient goals.

⭐ Physician Orders for Life-Sustaining Treatment (POLST) forms are immediately actionable medical orders, unlike advance directives (like living wills), which require a determination of incapacity.

Guidelines for End-of-Life Conversations

Special Considerations - When Rules Get Fuzzy

Perioperative DNRs: Not automatically suspended. Requires a formal "Required Reconsideration" discussion with the patient or surrogate before the procedure.
Rationale: Anesthesia and surgery introduce physiologic stress and risks (e.g., hypotension, arrhythmias) that are often iatrogenic and reversible.
Management Options:
- Full Suspension: Temporarily rescind the DNR for the perioperative period.
- Partial Modification: Specify acceptable interventions (e.g., defibrillation, vasopressors) while prohibiting others (e.g., chest compressions).
- Continuation: Uphold the DNR without changes.
Conflict Resolution: Involve the ethics committee if consensus cannot be reached.

⭐ The goal of the reconsideration discussion is to align the patient's end-of-life wishes with the specific, often reversible, risks of the perioperative period, thereby upholding patient autonomy.

High‑Yield Points - ⚡ Biggest Takeaways

A DNR/DNAR order must be a written, documented medical order in the patient's chart.

Patients with decision-making capacity have the right to request or refuse resuscitation.

For patients lacking capacity, decisions are guided by an advance directive or a designated healthcare surrogate.

DNR orders apply only to CPR; they do not mean "do not treat" other medical conditions.

Providers cannot act against patient/surrogate wishes, except in rare cases of medical futility.

Orders should be regularly reviewed, especially when the patient's clinical condition changes.

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DNR/DNAR orders