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?
Q2
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?
Q3
A 67-year-old man presents to the emergency department following an episode of chest pain and a loss of consciousness. The patient is in critical condition and his vital signs are rapidly deteriorating. It is known that the patient is currently undergoing chemotherapy for Hodgkin’s lymphoma. The patient is accompanied by his wife, who wants the medical staff to do everything to resuscitate the patient and bring him back. The patient also has 2 daughters, who are on their way to the hospital. The patient’s written advance directive states that the patient does not wish to be resuscitated or have any sort of life support. Which of the following is the appropriate course of action?
Q4
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?
Q5
A 76-year-old woman is brought to the physician by her daughter for evaluation of progressive cognitive decline and a 1-year history of incontinence. She was diagnosed with dementia, Alzheimer type, 5 years ago. The daughter has noticed that in the past 2 years, her mother has had increasing word-finding difficulties and forgetfulness. She was previously independent but now lives with her daughter and requires assistance with all activities of daily living. Over the past year, she has had decreased appetite, poor oral intake, and sometimes regurgitates her food. During this time, she has had a 12-kg (26-lb) weight loss. She was treated twice for aspiration pneumonia and now her diet mainly consists of pureed food. She has no advance directives and her daughter says that when her mother was independent the patient mentioned that she would not want any resuscitation or life-sustaining measures if the need arose. The daughter wants to continue taking care of her mother but is concerned about her ability to do so. The patient has hypertension and hyperlipidemia. Current medications include amlodipine and atorvastatin. Vital signs are within normal limits. She appears malnourished but is well-groomed. The patient is oriented to self and recognizes her daughter by name, but she is unaware of the place or year. Mini-Mental State Examination score is 17/30. Physical and neurologic examinations show no other abnormalities. A complete blood count and serum concentrations of creatinine, urea nitrogen, TSH, and vitamin B12 levels are within the reference range. Her serum albumin is 3 g/dL. Urinalysis shows no abnormalities. Which of the following is the most appropriate next step in management?
Q6
A 56-year-old man with chronic kidney disease and type 2 diabetes mellitus is brought to the emergency department by his neighbor because of impaired consciousness and difficulty speaking for 1 hour. A diagnosis of acute ischemic stroke is made. Over the next three days after admission, the patient’s renal function slowly worsens and hemodialysis is considered. He is not alert and cannot communicate. The neighbor, who has been a close friend for many years, says that the patient has always emphasized he would refuse dialysis or any other life-prolonging measures. He also reports that the patient has no family besides his father, who he has not seen for many years. His wife died 2 years ago. Which of the following is the most appropriate action by the physician?
Q7
Four days after being hospitalized, intubated, and mechanically ventilated, a 30-year-old man has no cough response during tracheal suctioning. He was involved in a motor vehicle collision and was obtunded on arrival in the emergency department. The ventilator is at a FiO2 of 100%, tidal volume is 920 mL, and positive end-expiratory pressure is 5 cm H2O. He is currently receiving vasopressors. His vital signs are within normal limits. The pupils are dilated and nonreactive to light. Corneal, gag, and oculovestibular reflexes are absent. There is no facial or upper extremity response to painful stimuli; the lower extremities show a triple flexion response to painful stimuli. Serum concentrations of electrolytes, urea, creatinine, and glucose are within the reference range. Arterial blood gas shows:
pH 7.45
pCO2 41 mm Hg
pO2 99 mm Hg
O2 saturation 99%
Two days ago, a CT scan of the head showed a left intracerebral hemorrhage with mass effect. The apnea test is positive. There are no known family members, advanced directives, or individuals with power of attorney. Which of the following is the most appropriate next step in management?
Q8
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?
Q9
One week after admission to the hospital for an extensive left middle cerebral artery stroke, a 91-year-old woman is unable to communicate, walk, or safely swallow food. She has been without nutrition for the duration of her hospitalization. The patient's sister requests placement of a percutaneous endoscopic gastrostomy tube for nutrition. The patient's husband declines the intervention. There is no living will. Which of the following is the most appropriate course of action by the physician?
Q10
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?
End-of-life care US Medical PG Practice Questions and MCQs
Question 1: 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?
A. Intubate the patient - the family is representing the patient's most recent and accurate wishes
B. Consult the hospital ethics committee
C. Do not intubate the patient given his living will (Correct Answer)
D. Intubate the patient - a patient's next of kin take precedence over a living will
E. Do not intubate the patient as his prognosis is poor even with intubation
Explanation: ***Do not intubate the patient given his living will***
- A **living will** or **advance directive** is a legally binding document that outlines a patient's wishes regarding medical treatment, including refusal of specific interventions like intubation.
- When the patient is **competent**, their stated wishes are paramount; when they are **incapacitated**, their advance directive becomes the primary guide for care decisions.
*Intubate the patient - the family is representing the patient's most recent and accurate wishes*
- While family input is valuable, a **legally executed living will** takes precedence over family opinions, especially when there's a conflict regarding specific life-sustaining treatments like intubation.
- There is no evidence presented that the patient has **revoked or updated** his living will.
*Consult the hospital ethics committee*
- While an ethics committee can provide guidance in complex cases, the patient's living will provides **clear instructions** that should be followed directly, making an immediate ethics committee consultation less necessary for this specific decision.
- The primary role of the ethics committee is to address **ambiguity or conflict** in patient care, which is not present regarding the patient's explicit refusal of intubation.
*Intubate the patient - a patient's next of kin take precedence over a living will*
- This statement is incorrect; a **valid living will** *takes precedence* over the wishes of the next of kin when the patient is unable to express their current desires.
- The next of kin's role is to act as a **surrogate decision-maker** only when a patient lacks capacity and has no advance directive that covers the specific situation.
*Do not intubate the patient as his prognosis is poor even with intubation*
- While a **poor prognosis** can be a factor in end-of-life discussions, the primary reason for not intubating in this scenario is the patient's explicit refusal documented in his **living will**, not solely the prognosis.
- Relying *only* on prognosis without considering the patient's prior stated wishes can undermine **patient autonomy**.
Question 2: 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
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.
Question 3: A 67-year-old man presents to the emergency department following an episode of chest pain and a loss of consciousness. The patient is in critical condition and his vital signs are rapidly deteriorating. It is known that the patient is currently undergoing chemotherapy for Hodgkin’s lymphoma. The patient is accompanied by his wife, who wants the medical staff to do everything to resuscitate the patient and bring him back. The patient also has 2 daughters, who are on their way to the hospital. The patient’s written advance directive states that the patient does not wish to be resuscitated or have any sort of life support. Which of the following is the appropriate course of action?
A. Consult a judge
B. Respect the patient’s advance directive orders (Correct Answer)
C. Contact the patient’s siblings or other first-degree relatives
D. Take into account the best medical decision made by the physician for the patient
E. Respect the wife’s wishes and resuscitate the patient
Explanation: ***Respect the patient’s advance directive orders***
- **Advance directives** legally document a patient's wishes regarding medical treatment, including end-of-life care, and must be honored if the patient is unable to make decisions.
- The patient's previously expressed autonomous decision, through a **written advance directive**, carries legal and ethical precedence over the wishes of family members or medical staff.
*Consult a judge*
- Consulting a judge is typically reserved for situations where there is **ambiguity or dispute** regarding the interpretation of an advance directive, or when no advance directive exists and family members disagree.
- In this case, the **written advance directive is clear**, making judicial intervention unnecessary.
*Contact the patient’s siblings or other first-degree relatives*
- Although family input can be valuable in some medical decisions, it does not **override a legally binding advance directive** made by the patient.
- The **patient's own wishes** are paramount, especially when clearly documented.
*Take into account the best medical decision made by the physician for the patient*
- While physicians provide medical expertise, patient **autonomy and established advance directives** take precedence over a physician's "best medical decision," especially regarding resuscitation.
- The physician's role here is to **implement the patient's documented wishes**, not to countermand them.
*Respect the wife’s wishes and resuscitate the patient*
- The wife's wishes, while important for emotional support, **do not legally or ethically supersede** the patient's explicit, written advance directive regarding resuscitation.
- Honoring the wife's request would violate the patient's **right to self-determination** and their previously stated wishes.
Question 4: 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
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.
Question 5: A 76-year-old woman is brought to the physician by her daughter for evaluation of progressive cognitive decline and a 1-year history of incontinence. She was diagnosed with dementia, Alzheimer type, 5 years ago. The daughter has noticed that in the past 2 years, her mother has had increasing word-finding difficulties and forgetfulness. She was previously independent but now lives with her daughter and requires assistance with all activities of daily living. Over the past year, she has had decreased appetite, poor oral intake, and sometimes regurgitates her food. During this time, she has had a 12-kg (26-lb) weight loss. She was treated twice for aspiration pneumonia and now her diet mainly consists of pureed food. She has no advance directives and her daughter says that when her mother was independent the patient mentioned that she would not want any resuscitation or life-sustaining measures if the need arose. The daughter wants to continue taking care of her mother but is concerned about her ability to do so. The patient has hypertension and hyperlipidemia. Current medications include amlodipine and atorvastatin. Vital signs are within normal limits. She appears malnourished but is well-groomed. The patient is oriented to self and recognizes her daughter by name, but she is unaware of the place or year. Mini-Mental State Examination score is 17/30. Physical and neurologic examinations show no other abnormalities. A complete blood count and serum concentrations of creatinine, urea nitrogen, TSH, and vitamin B12 levels are within the reference range. Her serum albumin is 3 g/dL. Urinalysis shows no abnormalities. Which of the following is the most appropriate next step in management?
A. Prescribe oxycodone
B. Short-term rehabilitation
C. Home hospice care (Correct Answer)
D. Inpatient palliative care
E. Evaluation for alternative methods of feeding
Explanation: ***Home hospice care***
- This patient exhibits advanced **dementia** with significant decline in function, frequent aspiration events, and substantial **weight loss**, indicating a prognosis of less than six months. **Hospice care** focuses on comfort and dignity during the end-of-life stage.
- The daughter's recollection of the patient's wishes to avoid life-sustaining measures, combined with the current medical complexity and poor prognosis, supports the transition to **hospice services** to manage symptoms and provide support to both the patient and family.
*Prescribe oxycodone*
- There is no mention of pain in the patient’s presentation; therefore, prescribing an **opioid** like oxycodone is not indicated and could cause adverse effects such as **sedation** and **constipation**, which would further complicate her care.
- While patients with advanced dementia may experience pain, it must be assessed and confirmed before prescribing **analgesics**.
*Short-term rehabilitation*
- Given the patient's advanced dementia, severe functional decline, recurrent aspiration pneumonia, and malnourishment, **short-term rehabilitation** to improve functional status is unlikely to be effective.
- The patient's underlying condition is progressive and irreversible, making restoration of independent function an unrealistic goal.
*Inpatient palliative care*
- While **palliative care** focuses on symptom management and quality of life, **inpatient palliative care** is typically reserved for patients with severe symptoms requiring constant medical attention that cannot be managed at home.
- In this case, the patient's symptoms, while serious, appear amenable to management in a home setting with the comprehensive support offered by **hospice**.
*Evaluation for alternative methods of feeding*
- In advanced dementia, **percutaneous endoscopic gastrostomy (PEG) tube feeding** does not improve survival, reduce aspiration risk, or enhance quality of life.
- Given the patient's advanced stage of disease and the recalled wishes to avoid life-sustaining measures, initiating **artificial feeding** would be contrary to comfort-focused care.
Question 6: A 56-year-old man with chronic kidney disease and type 2 diabetes mellitus is brought to the emergency department by his neighbor because of impaired consciousness and difficulty speaking for 1 hour. A diagnosis of acute ischemic stroke is made. Over the next three days after admission, the patient’s renal function slowly worsens and hemodialysis is considered. He is not alert and cannot communicate. The neighbor, who has been a close friend for many years, says that the patient has always emphasized he would refuse dialysis or any other life-prolonging measures. He also reports that the patient has no family besides his father, who he has not seen for many years. His wife died 2 years ago. Which of the following is the most appropriate action by the physician?
A. Start dialysis when required
B. Consult ethics committee
C. Try to contact the father for consent (Correct Answer)
D. Avoid dialysis in line with the patient's wishes
E. File for legal guardianship
Explanation: ***Try to contact the father for consent***
- In the absence of an advance directive or designated healthcare proxy, the **surrogate decision-maker hierarchy** applies, with parents being the appropriate next-of-kin for an adult patient without a spouse or children.
- Even though the patient is estranged from his father, the physician has a **legal and ethical obligation** to attempt to contact the father as the closest living relative before pursuing other options.
- The father has **legal standing** to make medical decisions for his adult son who lacks capacity, and estrangement alone does not remove this authority.
- Only if the father **cannot be located** or **refuses to participate** in decision-making should alternative approaches (such as ethics committee consultation) be pursued.
*Consult ethics committee*
- An ethics committee consultation is appropriate when there is **conflict between surrogates**, uncertainty about the patient's wishes with **no available surrogate**, or ethical dilemmas that cannot be resolved through standard channels.
- In this case, the father should be contacted **first** as the appropriate next-of-kin before escalating to an ethics committee.
- Ethics consultation would be the next step if the father cannot be reached or if there is conflict between the father's decision and the friend's report of the patient's wishes.
*Avoid dialysis in line with the patient's wishes*
- While respecting patient autonomy is paramount, the wishes are reported by a **friend** and are not formalized in an **advance directive** or living will.
- Friends do not have legal standing as surrogate decision-makers in the standard hierarchy.
- Withholding life-saving treatment based solely on a friend's testimony without consulting the legal next-of-kin could expose the physician to legal liability.
*Start dialysis when required*
- While this would preserve life, initiating major medical intervention without attempting to identify and contact the appropriate surrogate decision-maker violates **ethical standards** for informed consent.
- The friend's report of the patient's wishes against dialysis should not be ignored entirely, and proper decision-making processes should be followed.
*File for legal guardianship*
- Guardianship is a **lengthy legal process** that typically takes weeks to months and is not appropriate for acute, time-sensitive medical decisions.
- Guardianship should only be pursued when no next-of-kin can be identified or when there are ongoing concerns about decision-making capacity that extend beyond the acute situation.
Question 7: Four days after being hospitalized, intubated, and mechanically ventilated, a 30-year-old man has no cough response during tracheal suctioning. He was involved in a motor vehicle collision and was obtunded on arrival in the emergency department. The ventilator is at a FiO2 of 100%, tidal volume is 920 mL, and positive end-expiratory pressure is 5 cm H2O. He is currently receiving vasopressors. His vital signs are within normal limits. The pupils are dilated and nonreactive to light. Corneal, gag, and oculovestibular reflexes are absent. There is no facial or upper extremity response to painful stimuli; the lower extremities show a triple flexion response to painful stimuli. Serum concentrations of electrolytes, urea, creatinine, and glucose are within the reference range. Arterial blood gas shows:
pH 7.45
pCO2 41 mm Hg
pO2 99 mm Hg
O2 saturation 99%
Two days ago, a CT scan of the head showed a left intracerebral hemorrhage with mass effect. The apnea test is positive. There are no known family members, advanced directives, or individuals with power of attorney. Which of the following is the most appropriate next step in management?
A. Ethics committee consultation (Correct Answer)
B. Remove the ventilator
C. Court order for further management
D. Repeat CT scan of the head
E. Cerebral angiography
Explanation: ***Ethics committee consultation***
- The patient meets criteria for **brain death**, but there are no family members or advance directives to guide end-of-life decisions. An **ethics committee consultation** is essential to navigate the complex legal and ethical implications of withdrawing life support in such a situation.
- The committee can provide guidance on hospital policies, relevant laws, and ethical principles to ensure a decision that respects the patient's presumed wishes and societal values, especially given the absence of surrogates.
*Remove the ventilator*
- While the patient appears to meet the criteria for **brain death**, premature withdrawal of the ventilator without proper legal and ethical guidance is inappropriate, especially given the lack of identified next of kin or advance directives.
- A formal process, including definitive declaration of brain death by two separate physicians and addressing legal and ethical considerations, must precede such an action.
*Court order for further management*
- A court order might be necessary if there are intractable disagreements among stakeholders or if brain death cannot be definitively declared. However, an **ethics committee consult** is typically the initial step to resolve complex cases lacking surrogate decision-makers before escalating to legal action.
- Seeking a court order is a more extreme measure usually reserved when internal hospital mechanisms and ethical consultations fail to provide a clear path forward.
*Repeat CT scan of the head*
- A repeat CT scan would typically be performed to assess changes in the intracerebral hemorrhage or mass effect if there were signs of ongoing neurological deterioration that might be reversible, or to guide surgical intervention.
- However, in this patient, the clinical picture, including absent brainstem reflexes and a positive apnea test indicating **brain death**, suggests that further imaging for diagnostic purposes related to hemorrhage progression is unlikely to alter the prognosis or management related to end-of-life decisions.
*Cerebral angiography*
- **Cerebral angiography** is used to assess cerebral blood flow and can be a confirmatory test for brain death if clinical examination and apnea testing are inconclusive, especially in cases where sedative medications might confound the clinical picture.
- In this case, the comprehensive clinical examination and positive apnea test strongly suggest brain death, making angiography unnecessary at this stage, particularly without surrogate decision-makers.
Question 8: 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?
A. “We will take every measure necessary to prolong her life.”
B. “She may be eligible for hospice care.”
C. “The opinion of her primary care physician must be obtained regarding further steps in management.”
D. “Based on her wishes, mechanical ventilation must be discontinued.” (Correct Answer)
E. “Further management decisions will be referred to the hospital’s ethics committee.”
Explanation: ***Based on her wishes, mechanical ventilation must be discontinued.***
- A **living will** is a legally binding document that outlines a patient's wishes regarding medical treatment, including **refusal of life support**.
- In this scenario, the patient’s clear and documented wishes in her living will take precedence over the son's objections, even though he holds **durable power of attorney for healthcare** (DPA).
*“We will take every measure necessary to prolong her life.”*
- This statement directly contradicts the patient's **documented wishes** in her living will to refuse intubation and maintenance on mechanical ventilation.
- Ignoring a patient's advance directive can lead to ethical and legal issues, as it undermines the principle of **patient autonomy**.
*“She may be eligible for hospice care.”*
- While hospice care is a relevant consideration for patients with terminal illnesses, suggesting it prematurely without addressing the immediate issue of the **living will** can be dismissive of the patient's explicit directives.
- The primary concern is upholding the patient's autonomy, which includes addressing her advance directive regarding **withdrawal of life support**.
*“The opinion of her primary care physician must be obtained regarding further steps in management.”*
- While the **primary care physician's** input is valuable for understanding the patient's overall health and discussing goals of care, the existence of a clear and legally binding **living will** simplifies the decision-making process concerning life support.
- The patient's advance directive is paramount and generally does not require further medical negotiation unless there's ambiguity or new information suggesting a change in her wishes.
*“Further management decisions will be referred to the hospital’s ethics committee.”*
- An **ethics committee** consultation may be appropriate in cases of ambiguity surrounding an advance directive, conflict among surrogates, or uncertainty about the patient's capacity at the time of signing the directive.
- However, in this case, the **living will** explicitly states her wishes regarding mechanical ventilation, making the patient's intent clear and generally overriding the need for an ethics committee in the initial response.
Question 9: One week after admission to the hospital for an extensive left middle cerebral artery stroke, a 91-year-old woman is unable to communicate, walk, or safely swallow food. She has been without nutrition for the duration of her hospitalization. The patient's sister requests placement of a percutaneous endoscopic gastrostomy tube for nutrition. The patient's husband declines the intervention. There is no living will. Which of the following is the most appropriate course of action by the physician?
A. Encourage a family meeting (Correct Answer)
B. Initiate total parenteral nutrition
C. Consult the hospital ethics committee
D. Proceed with PEG placement
E. Transfer to a physician specialized in hospice care
Explanation: ***Encourage a family meeting***
- In situations of **disagreement among family members** regarding a patient's care, especially when there's no pre-existing expressed wish like a living will, a **family meeting is crucial** to facilitate open communication and achieve consensus.
- This step allows all relevant family members to discuss the patient's best interests, values, and potential wishes, guided by the medical team's input, to determine the most appropriate course of action.
*Initiate total parenteral nutrition*
- Initiating total parenteral nutrition (TPN) is a medical intervention that brings its own risks and benefits and should only be considered after a **clear decision has been made about the patient's long-term nutritional support**.
- TPN is not a solution for family disagreement, and can be more invasive than a PEG for long-term nutrition, and does not directly address the ethical dilemma of conflicting family wishes.
*Consult the hospital ethics committee*
- While an ethics committee consultation may be necessary if a resolution cannot be reached through a family meeting, it is generally considered a **later step** in managing such conflicts.
- The initial priority is to foster communication and consensus among the family members themselves before escalating to an external review body.
*Proceed with PEG placement*
- Proceeding with PEG placement when there is a **direct conflict between immediate family members** (sister versus husband) and no clear advance directive would be inappropriate and could lead to significant ethical and legal challenges.
- Patient autonomy, even through a surrogate, must be respected, and acting unilaterally without resolving the family dispute would be a breach of this principle.
*Transfer to a physician specialized in hospice care*
- Transferring the patient to hospice care implies a decision has been made to focus on comfort care and forego aggressive interventions, which is precisely the point of contention among the family.
- This action would be **premature and inappropriate** as long as there is an unresolved disagreement about the goals of care and whether a PEG should be placed or not.
Question 10: 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?
A. Once she enters hospice
B. Now that she is ill, speaking about advance directives is no longer an option
C. Only if her curative surgical and medical treatment fails
D. Only if she initiates the conversation
E. At this visit (Correct Answer)
Explanation: ***At this visit***
- Advance care planning should ideally be initiated as soon as a **serious illness** like pancreatic cancer is diagnosed, while the patient still has the capacity to make informed decisions.
- This allows the patient to clearly state their **wishes** for future medical care and designate a **surrogate decision-maker**.
*Once she enters hospice*
- Delaying discussions until hospice care often means the patient's condition has significantly deteriorated, potentially impacting their ability to actively participate in **decision-making**.
- While advance directives are crucial for hospice patients, starting earlier ensures their preferences guide all stages of their care, not just the end-of-life phase.
*Now that she is ill, speaking about advance directives is no longer an option*
- This statement is incorrect as illness is often the **catalyst** for initiating advance care planning, not a barrier.
- Patients often appreciate the opportunity to discuss their wishes, especially when facing a serious diagnosis, to maintain a sense of **control** and ensure their autonomy.
*Only if her curative surgical and medical treatment fails*
- Waiting until treatment failure is too late as the patient's condition may have worsened to a point where they are no longer able to engage in **meaningful discussions** or have decreased mental capacity.
- Advance care planning is about preparing for potential future scenarios, not just reacting to immediate failures; it provides a framework for care regardless of **treatment outcomes**.
*Only if she initiates the conversation*
- While patient initiation is ideal, it is the physician's responsibility to bring up these important discussions, especially with a new diagnosis of a serious illness like **pancreatic cancer**.
- Many patients may not know about advance directives or feel comfortable initiating such a sensitive conversation, so the physician should proactively offer the **opportunity**.
Question 11: A 73-year-old man presents to his primary care physician endorsing 4-5 days of decreased urinary output and mild shortness of breath. He has a complex medical history, including uncontrolled diabetes mellitus type 2, hypertension, chronic kidney disease, and end-stage emphysema. It is determined that his kidney disease has progressed to the point of needing dialysis, which his primary care physician feels should be initiated promptly. However, the patient remarks, "I would never want dialysis. I have friends who went through it, and it sounds awful. I would rather die comfortably, even if that is soon." After the physician explains what dialysis is, and the risks and alternatives to the procedure the patient is able to demonstrate his understanding of dialysis including the risks, benefits and alternatives. He appears to be in no distress and demonstrates a clear understanding. After discussing the patient's wishes further, which of the following is the most appropriate response on the part of the physician?
A. "I will involve a psychiatrist to help determine your capacity to refuse this treatment"
B. "I will obtain an ethics consultation to help with this matter"
C. "I respect that this is ultimately your decision, and will focus on making sure you are comfortable" (Correct Answer)
D. "I cannot be your physician going forward if you refuse to undergo dialysis"
E. "I strongly encourage you to reconsider your decision"
Explanation: ***I respect that this is ultimately your decision, and will focus on making sure you are comfortable***
- Patients have the **right to refuse medical treatment** when they have the capacity to make informed decisions, even if that decision may lead to their death.
- The physician's role then shifts to providing **palliative care** and ensuring the patient's comfort and dignity, respecting their **autonomy**.
*I will involve a psychiatrist to help determine your capacity to refuse this treatment*
- The patient appears to be in **no distress** and demonstrates a **clear understanding** of the risks, benefits, and alternatives of dialysis, suggesting he has decision-making capacity.
- A psychiatric consultation is usually warranted when there are concerns about a patient's capacity due to mental illness, cognitive impairment, or significant emotional distress, none of which are explicitly stated here.
*I will obtain an ethics consultation to help with this matter*
- An ethics consultation is typically sought in cases of **ethical dilemmas** where there is significant disagreement or uncertainty among medical staff, family, or the patient about the appropriate course of action, or when there are conflicts of interest.
- In this scenario, the patient's wishes are clear, and there is no explicit conflict or dilemma stated that would immediately necessitate an ethics consultation.
*I cannot be your physician going forward if you refuse to undergo dialysis*
- This statement constitutes **patient abandonment**, which is unethical and potentially illegal.
- A physician has a professional obligation to continue care for a patient, even if the patient refuses a recommended treatment, and should transition to providing appropriate alternative care, such as palliative care.
*I strongly encourage you to reconsider your decision*
- While it's appropriate to ensure the patient fully understands the implications of their decision, "strongly encouraging" reconsideration after the patient has demonstrated clear understanding can be perceived as pressuring and may undermine their **autonomy**.
- The physician should have already thoroughly discussed the options and ensured comprehension, and further strong encouragement might infringe on the patient's right to choose.
Question 12: A 67-year-old patient comes to the physician because of a 4-month history of weight loss, chest pain, dry cough, and shortness of breath on exertion. He worked as a shipbuilder for 45 years and is now retired. Since the death of his wife 2 years ago, he has lived with his daughter. He has never smoked. His temperature is 38.1°C (100.6°F), pulse is 85/min, and blood pressure is 134/82 mm Hg. Fine, end-inspiratory rales are heard at the left lung base; breath sounds are absent at the right lung base. A CT scan of the chest shows pleural thickening and a right hemothorax. Thoracocentesis confirms the diagnosis of mesothelioma. The patient and his family are informed about the poor prognosis of this condition and that the mean survival time is 1 year. The patient states that he wishes to receive radiation. He would also like to receive home hospice care but is unsure whether his health insurance would cover the costs. The patient's son, who has been assigned power of attorney, does not agree with this decision. The patient does not have a living will but states that if his heart stops beating, he wants to receive cardiopulmonary resuscitation. Which of the following disqualifies the patient from receiving hospice care?
A. The son's objection
B. His life expectancy
C. Lack of living will
D. Uncertain coverage by health insurance
E. Wish for cardiopulmonary resuscitation (Correct Answer)
Explanation: ***Wish for cardiopulmonary resuscitation***
- **Hospice care** focuses on **palliative care** and comfort for patients with a **terminal illness** and a prognosis of **six months or less**, aiming to ensure a peaceful death, free from aggressive life-sustaining treatments.
- Requesting **cardiopulmonary resuscitation (CPR)** contradicts the philosophy of hospice care, as CPR is an **aggressive medical intervention** intended to prolong life, which is against the principles of hospice.
*The son's objection*
- The patient, being of **sound mind** and having the capacity to make his own medical decisions, has the right to choose hospice care regardless of his son's preferences.
- The **power of attorney** (POA) only becomes active if the patient is **incapacitated** and unable to make decisions for himself; since he is deemed capable, his wishes take precedence.
*His life expectancy*
- A mean survival time of **1 year** with mesothelioma makes the patient eligible for hospice care, as hospice typically requires a prognosis of **six months or less** if the disease runs its expected course.
- Even with a prognosis slightly over six months, patients can still qualify for hospice if their condition is expected to **decline** and meet the six-month criterion over time.
*Lack of living will*
- While a **living will** (advance directive) is beneficial for documenting end-of-life wishes, its absence does **not disqualify** a patient from receiving hospice care.
- A patient can still make their wishes known verbally or through other legal documents, and hospice will honor those preferences as long as the patient is **competent**.
*Uncertain coverage by health insurance*
- **Health insurance coverage** is an administrative and financial issue, not a clinical criterion for hospice eligibility.
- Many insurance plans, including **Medicare** and **Medicaid**, cover hospice care, and financial concerns should be addressed but do not medically disqualify a patient.
Question 13: 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?
A. Call other family members and consult them for their opinions
B. Listen to the patient’s daughter’s wishes and continue all care
C. Compromise between the wife and daughter and withdraw the fluids and antibiotics but keep the patient intubated
D. Listen to the patient’s wife’s wishes and withdraw care (Correct Answer)
E. Consult the hospital ethics committee and continue all care until a decision is reached
Explanation: ***Listen to the patient’s wife’s wishes and withdraw care***
- The **durable power of attorney for healthcare** legally designates the wife as the patient's surrogate decision-maker when the patient lacks capacity, overriding other family opinions.
- In the absence of a living will, the **surrogate's interpretation of the patient's best interests** and previously expressed wishes is legally and ethically binding.
*Call other family members and consult them for their opinions*
- While involving family is good practice in general, the presence of a **legally appointed durable power of attorney** means that other family members' opinions do not supersede the designated surrogate's decisions.
- Consulting other family members could **create more conflict and delay** crucial decisions, as the wife holds the legal authority.
*Listen to the patient’s daughter’s wishes and continue all care*
- The daughter's wishes, while understandable, **do not hold legal authority** over the decisions of the legally appointed durable power of attorney.
- Disregarding the wife's authority would be a **breach of ethical and legal obligations** in patient care.
*Compromise between the wife and daughter and withdraw the fluids and antibiotics but keep the patient intubated*
- A compromise that goes against the legal surrogate's explicitly stated decision (to withdraw all care) is **ethically problematic and legally unsound**.
- Healthcare decisions should be based on the patient's best interest as interpreted by the **authorized surrogate**, not on attempting to please all family members.
*Consult the hospital ethics committee and continue all care until a decision is reached*
- While an ethics committee consult is appropriate if there's **disagreement over the interpretation of the patient's wishes** *among legally designated surrogates* or concerns about the surrogate's decision-making capacity, it's not the first step when a clear legal surrogate with documentation is present and makes a decision.
- Continuing all care against the wishes of the **legal proxy** would be contrary to patient autonomy and the principles of substituted judgment.
