Futility and medical judgment — MCQs

10 questions

A 29-year-old man is admitted to the emergency department following a motorcycle accident. The patient is severely injured and requires life support after splenectomy and evacuation of a subdural hematoma. Past medical history is unremarkable. The patient’s family members, including wife, parents, siblings, and grandparents, are informed about the patient’s condition. The patient has no living will and there is no durable power of attorney. The patient must be put in an induced coma for an undetermined period of time. Which of the following is responsible for making medical decisions for the incapacitated patient?

A 19-year-old woman is diagnosed with metastatic Ewing sarcoma. She has undergone multiple treatments without improvement. She decides to stop treatment and pursue only palliative care. She is of sound mind and has weighed the benefits and risks of this decision. The patient’s mother objects and insists that treatments be continued. What should be done?

An 87-year-old man with glioblastoma multiforme is informed that the size and location of the tumor make operative resection impossible, and he has a prognosis of between 3-6 months. The patient then asks whether it would be possible to get a prescription for lethal medications so that he would be able to end his life if his situation deteriorated further. The physician says that he is unable to prescribe such drugs because assisted suicide is not legal in their state. Refusing to help a patient commit suicide is most consistent with which of the following ethical principles?

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 terminally ill patient with advanced cancer requests that no resuscitation be performed in the event of cardiac arrest. The patient is mentally competent and has completed advance directives. A family member later demands full resuscitation efforts. Which of the following is the most appropriate response?

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 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 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?

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?

Q10

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?

Futility and medical judgment US Medical PG Practice Questions and MCQs

Question 1: A 29-year-old man is admitted to the emergency department following a motorcycle accident. The patient is severely injured and requires life support after splenectomy and evacuation of a subdural hematoma. Past medical history is unremarkable. The patient’s family members, including wife, parents, siblings, and grandparents, are informed about the patient’s condition. The patient has no living will and there is no durable power of attorney. The patient must be put in an induced coma for an undetermined period of time. Which of the following is responsible for making medical decisions for the incapacitated patient?

A. The spouse (Correct Answer)
B. An older sibling
C. Physician
D. Legal guardian
E. The parents

Explanation: ***The spouse*** - In the absence of a **living will** or **durable power of attorney**, the law typically designates the **spouse** as the primary decision-maker for an incapacitated patient. - This hierarchy is established to ensure decisions are made by the individual most intimately connected and presumed to understand the patient's wishes. *An older sibling* - Siblings are generally further down the **hierarchy of surrogate decision-makers** than a spouse or parents. - They would typically only be considered if higher-priority family members are unavailable or unwilling to make decisions. *Physician* - The physician's role is to provide medical care and guidance, not to make medical decisions for an incapacitated patient when family surrogates are available. - Physicians only make decisions in **emergency situations** when no surrogate is immediately available and treatment is immediately necessary to save the patient's life or prevent serious harm. *Legal guardian* - A legal guardian is usually appointed by a **court** when there is no appropriate family member available or when there is a dispute among family members. - In this scenario, with a spouse and other close family members present, a legal guardian would not be the first choice. *The parents* - While parents are close family members, they are typically considered **secondary to the spouse** in the hierarchy of surrogate decision-makers for an adult patient. - They would usually only be the decision-makers if the patient were unmarried or the spouse were unavailable.

Question 2: A 19-year-old woman is diagnosed with metastatic Ewing sarcoma. She has undergone multiple treatments without improvement. She decides to stop treatment and pursue only palliative care. She is of sound mind and has weighed the benefits and risks of this decision. The patient’s mother objects and insists that treatments be continued. What should be done?

A. Try to seek additional experimental treatments that are promising.
B. Follow the wishes of the patient’s mother as she has decision making power for the patient.
C. Continue treatments until the patient has a psychiatric evaluation.
D. Continue treatment because otherwise, the patient will die.
E. Halt treatments and begin palliative care. (Correct Answer)

Explanation: ***Halt treatments and begin palliative care.*** - An adult patient of **sound mind** has the right to refuse medical treatment, even if that refusal may lead to death. This principle is a cornerstone of **patient autonomy**. - The patient has clearly expressed her wishes after weighing the benefits and risks, making her decision legally and ethically binding. *Try to seek additional experimental treatments that are promising.* - While seeking additional treatments might be an option if the patient desired it, forcing such treatments against her will violates her **autonomy** and right to self-determination. - The case states the patient has decided to stop treatment, making further treatment exploration against her expressed wishes. *Follow the wishes of the patient’s mother as she has decision making power for the patient.* - The patient is 19 years old, making her a **legal adult**, and therefore her mother does not have decision-making power over her medical care. - The patient's mother's wishes, while understandable from an emotional perspective, do not supersede the **competent adult patient's** right to make her own medical decisions. *Continue treatments until the patient has a psychiatric evaluation.* - The patient is described as being of "sound mind" and having "weighed the benefits and risks," indicating she is making an informed decision. - Requesting a psychiatric evaluation without clear evidence of impaired mental capacity would be a disrespectful and unethical attempt to override her **autonomously made decision**. *Continue treatment because otherwise, the patient will die.* - While it is true that stopping treatment will likely lead to death, a **competent adult patient** has the right to refuse life-sustaining treatment. - The patient's right to **autonomy** and control over her own body takes precedence over the desire of others (including medical professionals or family) to prolong life against her will.

Question 3: An 87-year-old man with glioblastoma multiforme is informed that the size and location of the tumor make operative resection impossible, and he has a prognosis of between 3-6 months. The patient then asks whether it would be possible to get a prescription for lethal medications so that he would be able to end his life if his situation deteriorated further. The physician says that he is unable to prescribe such drugs because assisted suicide is not legal in their state. Refusing to help a patient commit suicide is most consistent with which of the following ethical principles?

A. Beneficence
B. Distributive justice
C. Non-maleficence (Correct Answer)
D. Autonomy
E. Formal justice

Explanation: ***Non-maleficence*** - Non-maleficence is the ethical principle to **"do no harm"** to the patient, one of the four core pillars of medical ethics. - In the context of physician-assisted suicide, refusing to prescribe lethal medications is **most directly grounded** in the principle of not causing harm or death to the patient, even when requested. - While legal constraints exist, the **underlying ethical rationale** for opposition to physician-assisted suicide in traditional medical ethics is that actively ending a patient's life violates the fundamental duty not to harm. - This principle holds that the physician's role is to **preserve life and relieve suffering** through palliative care, not to cause death. *Formal justice* - Formal justice refers to the principle of treating **similar cases in a similar manner** and applying rules consistently. - While the physician is following the law equally for all patients, formal justice is more about **procedural fairness** than the substantive ethical principle underlying the refusal to end life. - This principle is relevant but is **not the primary ethical foundation** for opposing physician-assisted suicide. *Beneficence* - Beneficence is the ethical principle of acting in the **best interest of the patient** and promoting their well-being. - While some might argue that respecting the patient's wish could be beneficent, traditional medical ethics views **preserving life** and providing comfort care as beneficent, rather than facilitating death. - This principle could be invoked on either side of the debate but is **less specific** than non-maleficence in this context. *Autonomy* - Autonomy is the principle of respecting a patient's right to make **decisions about their own medical care**. - While the patient is expressing an autonomous wish, the physician's refusal demonstrates that autonomy has **limits when it conflicts** with other ethical principles (non-maleficence) and legal constraints. - This scenario represents a tension between autonomy and other ethical duties. *Distributive justice* - Distributive justice concerns the **fair allocation of resources** and burdens within society. - This principle is generally applied to situations involving healthcare access, resource scarcity, or equitable treatment for groups of people, and is **not directly relevant** to an individual physician's decision regarding assisted suicide.

Question 4: 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 5: A terminally ill patient with advanced cancer requests that no resuscitation be performed in the event of cardiac arrest. The patient is mentally competent and has completed advance directives. A family member later demands full resuscitation efforts. Which of the following is the most appropriate response?

A. Honor the patient's DNR (Correct Answer)
B. Obtain court order
C. Follow the family's wishes
D. Consult ethics committee

Explanation: ***Honor the patient's DNR*** - The patient is **mentally competent** and has legally documented their wishes through **advance directives** (DNR), which must be respected. - A competent patient's right to **autonomy** in making decisions about their medical care takes precedence over the wishes of family members. *Obtain court order* - Seeking a court order is **unnecessary** and **inappropriate** when a competent patient's wishes are clearly documented in advance directives. - This option would cause **undue delay** and legal entanglement, potentially going against the patient's immediate medical needs and preferences. *Follow the family's wishes* - Following the family's wishes would **override the patient's autonomy** and legally binding advance directives. - The family's emotional distress does not negate the patient's right to determine their own medical care, especially when they are competent. *Consult ethics committee* - While an ethics committee can be helpful in complex cases with **unclear directives** or patient capacity issues, it's not the first step here. - The patient's competence and clear advance directives make the decision straightforward; a committee consultation could cause delay and unnecessary burden.

Question 6: 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 7: 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 8: 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 9: 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 10: 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.

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