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?
Q12
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?
Q13
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?
End-of-life care US Medical PG Practice Questions and MCQs
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.
