Resource allocation ethics — MCQs

10 questions

A 5-year-old child is brought to the emergency department after being hit by a motor vehicle on the way to school. According to paramedics, the child's right leg was severely crushed in the accident. After evaluation, the physician recommends immediate limb-saving surgery to preserve the leg and prevent complications. However, the parents refuse to consent to the surgery. They explain that they heard about a similar case where a child died after limb-saving surgery, and they believe the procedure might lead to amputation or death. Despite the physician's explanation that the surgery is intended to save the limb, the parents remain adamant in their refusal. What is the next best step?

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 She mentions that he did not have a living will, but she believes that he would want care withdrawn in this situation, and therefore asks the team to withdraw care at this point.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 22-year-old man is brought to the emergency department by his friends 30 minutes after falling down a flight of stairs. His friends report that they were at a college party, where he drank large amounts of alcohol. He is aggressive and restless. Examination shows tenderness to palpation and swelling of his right lower leg. An x-ray of the right leg shows a lower tibial shaft fracture. The physician recommends overnight observation and surgery the following morning. The patient refuses the suggested treatment and requests immediate discharge. Otherwise, he says, he will call his lawyer and sue the entire medical staff involved in his care. Which of the following is the most appropriate response by the physician?

A 15-year-old teenager presents to the emergency department via emergency medical service (EMS) after a motor vehicle accident. The patient is in critical condition and is hemodynamically unstable. It becomes apparent that the patient may require a blood transfusion, and the parents are approached for consent. They are Jehovah’s Witnesses and deny the blood transfusion, saying it is against their beliefs. However, the patient insists that she wants the transfusion if it will save her life. Despite the patient’s wishes, the parents remain steadfast in their refusal to allow the transfusion. Which of the following is the most appropriate course of action?

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 psychiatrist receives a call from a patient who expresses thoughts of harming his ex-girlfriend. The patient describes a detailed plan to attack her at her workplace. Which of the following represents the psychiatrist's most appropriate legal obligation?

A 57-year-old man presents to his oncologist to discuss management of small cell lung cancer. The patient is a lifelong smoker and was diagnosed with cancer 1 week ago. The patient states that the cancer was his fault for smoking and that there is "no hope now." He seems disinterested in discussing the treatment options and making a plan for treatment and followup. The patient says "he does not want any treatment" for his condition. Which of the following is the most appropriate response from the physician?

A 69-year-old woman with acute myeloid leukemia comes to the physician to discuss future treatment plans. She expresses interest in learning more about an experimental therapy being offered for her condition. After the physician explains the mechanism of the drug and describes the risks and benefits, the patient then states that she is not ready to die. When the physician asks her what her understanding of the therapy is, she responds "I don't remember the details, but I just know that I definitely want to try it, because I don't want to die." Which of the following ethical principles is compromised in this physician's interaction with the patient?

A 72-year-old man is seen in the hospital for a sacral rash. The patient has been hospitalized for the past 3 weeks for a heart failure exacerbation. When the nurse went to bathe him this morning, she noticed a red rash over his sacrum. The patient reports mild discomfort and denies pruritus. The patient has chronic kidney disease, urinary incontinence, ischemic cardiomyopathy, gout, and poor mobility. His current medications include aspirin, furosemide, metoprolol, lisinopril, spironolactone, and prednisone that was started for a recent gout flare. The patient’s temperature is 97°F (37.2°C), blood pressure is 110/62 mmHg, pulse is 68/min, and respirations are 13/min with an oxygen saturation of 98% on room air. On physical examination, there is a 4 cm x 6 cm patch of non-blanchable erythema over the patient’s sacrum that is mildly tender to palpation. Labs are obtained, as shown below: Leukocyte count: 10,000/mm^3 with normal differential Hemoglobin: 15.2 g/dL Platelet count: 400,000/mm^3 Serum: Na: 138 mEq/L K+: 4.3 mEq/L Cl-: 104 mEq/L HCO3-: 25 mEq/L BUN: 26 mg/dL Creatinine: 1.5 mg/dL Glucose: 185 mg/dL A hemoglobin A1c is pending. Which of the following is the best management for the patient’s most likely diagnosis?

Q10

A patient was referred by a doctor to a radiologist for a CT scan and the doctor was given money for the referral. What is this unethical act called?

Resource allocation ethics US Medical PG Practice Questions and MCQs

Question 1: A 5-year-old child is brought to the emergency department after being hit by a motor vehicle on the way to school. According to paramedics, the child's right leg was severely crushed in the accident. After evaluation, the physician recommends immediate limb-saving surgery to preserve the leg and prevent complications. However, the parents refuse to consent to the surgery. They explain that they heard about a similar case where a child died after limb-saving surgery, and they believe the procedure might lead to amputation or death. Despite the physician's explanation that the surgery is intended to save the limb, the parents remain adamant in their refusal. What is the next best step?

A. Contact the next of kin
B. Ask for a court order
C. Take into account the child’s wishes
D. Take the parents' wishes into account
E. Inform the hospital Ethics Committee, state authority, and child protective services, and obtain a court order to proceed with treatment (Correct Answer)

Explanation: ***Inform the hospital Ethics Committee, state authority, and child protective services, and obtain a court order to proceed with treatment*** - When parents refuse **life-saving or limb-saving treatment** for a child, and the medical team believes the treatment is in the child's best interest, the case becomes a legal and ethical concern requiring immediate institutional and legal intervention. - The appropriate response involves **multiple parallel actions**: contacting the hospital **Ethics Committee** for guidance, notifying **Child Protective Services (CPS)** for suspected medical neglect, and seeking a **court order** to authorize treatment. - This comprehensive approach protects the child's welfare while respecting legal procedures. **Medical neglect** constitutes a form of child abuse, and the state has parens patriae authority to protect minor citizens when parents' decisions threaten serious harm. - In true life-threatening emergencies where delay would cause death or serious harm, physicians may proceed under emergency doctrine, but for urgent situations allowing time for legal process, a court order should be obtained. *Contact the next of kin* - While contacting other family members might provide support or alternative perspectives, it does not address the immediate legal and ethical obligations when parents refuse medically necessary care. - The parents are the legal guardians, and their refusal necessitates formal institutional and legal intervention rather than informal family consultation. *Ask for a court order* - While obtaining a **court order** is essential when parental consent is refused for necessary treatment, this option alone is incomplete. - The most appropriate immediate response involves the **comprehensive institutional approach**: simultaneously engaging the Ethics Committee for guidance, notifying CPS for child protection, and initiating the legal process for court authorization. - This multi-pronged approach ensures all stakeholders are involved and the child's interests are protected through proper channels. *Take into account the child's wishes* - A 5-year-old child lacks the **developmental capacity and legal standing** for informed consent regarding complex medical procedures. - While assent from older minors (typically 7+ years) may be considered for less critical decisions, a 5-year-old's wishes regarding limb-saving surgery are not determinative. - The focus must remain on the child's **best medical interest** as determined by medical professionals and legal frameworks, not the child's limited understanding at this developmental stage. *Take the parents' wishes into account* - While parental autonomy in medical decision-making is generally respected, this principle has limits when parental decisions would result in **significant harm, neglect, or death** to the child. - When parents refuse **medically indicated, life-saving, or limb-saving treatment**, their decision can and should be legally challenged through appropriate institutional and judicial channels to protect the child's welfare. - The state's interest in protecting children overrides parental preferences when those preferences threaten serious harm.

Question 2: 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.

Question 3: A 22-year-old man is brought to the emergency department by his friends 30 minutes after falling down a flight of stairs. His friends report that they were at a college party, where he drank large amounts of alcohol. He is aggressive and restless. Examination shows tenderness to palpation and swelling of his right lower leg. An x-ray of the right leg shows a lower tibial shaft fracture. The physician recommends overnight observation and surgery the following morning. The patient refuses the suggested treatment and requests immediate discharge. Otherwise, he says, he will call his lawyer and sue the entire medical staff involved in his care. Which of the following is the most appropriate response by the physician?

A. You can leave the hospital after signing a self-discharge against medical advice form.
B. If you don't consent to treatment, I'll be forced to obtain consent from your parents.
C. I understand that you want to go home, but I'll have to keep you here as long as you are intoxicated. (Correct Answer)
D. Have you ever felt you should cut down on your drinking?
E. I can't force you to stay here, but I'll have to inform your dean of this incident.

Explanation: ***I understand that you want to go home, but I'll have to keep you here as long as you are intoxicated.*** - An **intoxicated patient may lack decision-making capacity** to refuse medically necessary treatment for a serious injury. - Before accepting a refusal of treatment or allowing AMA discharge, physicians must **assess the patient's capacity** to make informed decisions. - Signs of impaired capacity include **acute intoxication, aggressive behavior, and restlessness**, all present in this patient. - Temporarily holding a patient who lacks capacity and has a serious medical condition requiring urgent care is **legally and ethically justified** to prevent harm—this is NOT false imprisonment. - Once the patient regains capacity (i.e., sobers up), his decision-making ability can be reassessed, and if he still refuses, AMA discharge can be offered. *You can leave the hospital after signing a self-discharge against medical advice form.* - While competent adults have the right to refuse treatment and leave AMA, this option is **premature** because it fails to address the patient's **impaired decision-making capacity** due to acute intoxication. - A valid refusal requires **capacity to understand the risks and consequences** of leaving—offering AMA discharge without capacity assessment is inappropriate and potentially negligent. *I can't force you to stay here, but I'll have to inform your dean of this incident.* - Threatening to inform the patient's dean is a **breach of confidentiality** and an unprofessional response. - Healthcare providers are bound by **patient confidentiality (HIPAA)**, and sharing this information without consent is unethical and illegal. *If you don't consent to treatment, I'll be forced to obtain consent from your parents.* - Since the patient is a **competent adult (age 22)**, his parents cannot give or withhold consent for his medical treatment. - Parental consent is only required for **minors** or adults who have been legally declared **incompetent** through a court process. *Have you ever felt you should cut down on your drinking?* - While addressing alcohol use disorder is important, asking a **CAGE screening question** in this acute, high-stress situation is **inappropriate timing** and poor prioritization. - The immediate priority is addressing the patient's **acute medical needs and impaired capacity**, not initiating a substance abuse screening.

Question 4: A 15-year-old teenager presents to the emergency department via emergency medical service (EMS) after a motor vehicle accident. The patient is in critical condition and is hemodynamically unstable. It becomes apparent that the patient may require a blood transfusion, and the parents are approached for consent. They are Jehovah’s Witnesses and deny the blood transfusion, saying it is against their beliefs. However, the patient insists that she wants the transfusion if it will save her life. Despite the patient’s wishes, the parents remain steadfast in their refusal to allow the transfusion. Which of the following is the most appropriate course of action?

A. Obtain a court order to give blood products. (Correct Answer)
B. Give the patient the blood transfusion.
C. Give intravenous fluids to attempt to stabilize the patient.
D. Do not give blood transfusion due to the parents’ refusal.
E. Consult the hospital ethics committee.

Explanation: ***Obtain a court order to give blood products.*** - In situations where a minor's life is at risk and parents refuse life-saving treatment, seeking a **court order** is the most appropriate action to protect the child's best interests. - This step allows the medical team to proceed with the necessary treatment despite parental objections, balancing the parents' religious freedom with the state's interest in protecting children. *Give the patient the blood transfusion.* - Directly proceeding with the transfusion without legal intervention against parental wishes for a minor could lead to **legal ramifications** and accusations of battery or lack of informed consent. - While the patient expresses a wish for the transfusion, due to her minor status, parental consent or a court order is generally required before proceeding against parental refusal. *Give intravenous fluids to attempt to stabilize the patient.* - While supportive measures like **intravenous fluids** are important, they may not be sufficient to stabilize a hemodynamically unstable patient requiring a blood transfusion. - Delaying definitive, necessary treatment in a critical situation can worsen the patient's condition and is not a substitute for addressing the need for blood products. *Do not give blood transfusion due to the parents’ refusal.* - Refusing to provide life-saving treatment to a minor when a less invasive alternative is unavailable, solely based on parental religious beliefs and despite the child's expressed wishes, could be considered **medical neglect** and runs contrary to the medical obligation to preserve life. - Even if the parents are steadfast, the healthcare team has an ethical and legal obligation to advocate for the minor's well-being, especially when the minor explicitly requests the treatment. *Consult the hospital ethics committee.* - While an **ethics committee** consultation is valuable for complex ethical dilemmas, it is typically a time-consuming process that may not be feasible for a critically ill, hemodynamically unstable patient requiring immediate intervention. - In urgent, life-threatening situations involving minors, the immediate priority is to secure the necessary treatment, often through direct legal channels, rather than waiting for an ethics committee review.

Question 5: 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 6: A psychiatrist receives a call from a patient who expresses thoughts of harming his ex-girlfriend. The patient describes a detailed plan to attack her at her workplace. Which of the following represents the psychiatrist's most appropriate legal obligation?

A. Warn the ex-girlfriend and notify law enforcement (Correct Answer)
B. Only notify the patient's family
C. Warn only law enforcement
D. Maintain patient confidentiality

Explanation: ***Warn the ex-girlfriend and notify law enforcement*** - This scenario directly triggers the **"duty to warn"** and **"duty to protect"** principles, primarily stemming from the **Tarasoff v. Regents of the University of California** case. - The psychiatrist has a legal obligation to take reasonable steps to protect the identifiable victim, which includes directly warning the intended victim and informing law enforcement. *Only notify the patient's family* - Notifying the patient's family alone does not fulfill the **legal obligation to protect** an identifiable third party from a serious threat of harm. - While family involvement might be part of a comprehensive safety plan, it is insufficient as the sole action in this critical situation. *Warn only law enforcement* - While notifying law enforcement is a crucial step, the **Tarasoff duty** specifically mandates warning the **intended victim** directly (or those who can reasonably be expected to notify the victim). - Relying solely on law enforcement might not ensure the immediate safety of the ex-girlfriend, especially if there's a delay in their response or ability to locate her. *Maintain patient confidentiality* - Patient confidentiality is a cornerstone of psychiatric practice, but it is **not absolute** when there is a serious and imminent threat of harm to an identifiable individual. - The **duty to protect** a potential victim *outweighs* the duty to maintain confidentiality in such extreme circumstances.

Question 7: A 57-year-old man presents to his oncologist to discuss management of small cell lung cancer. The patient is a lifelong smoker and was diagnosed with cancer 1 week ago. The patient states that the cancer was his fault for smoking and that there is "no hope now." He seems disinterested in discussing the treatment options and making a plan for treatment and followup. The patient says "he does not want any treatment" for his condition. Which of the following is the most appropriate response from the physician?

A. "You seem upset at the news of this diagnosis. I want you to go home and discuss this with your loved ones and come back when you feel ready to make a plan together for your care."
B. "It must be tough having received this diagnosis; however, new cancer therapies show increased efficacy and excellent outcomes."
C. "It must be very challenging having received this diagnosis. I want to work with you to create a plan." (Correct Answer)
D. "We are going to need to treat your lung cancer. I am here to help you throughout the process."
E. "I respect your decision and we will not administer any treatment. Let me know if I can help in any way."

Explanation: ***"It must be very challenging having received this diagnosis. I want to work with you to create a plan."*** - This response **acknowledges the patient's emotional distress** and feelings of guilt and hopelessness, which is crucial for building rapport and trust. - It also gently **re-engages the patient** by offering a collaborative approach to treatment, demonstrating the physician's commitment to supporting him through the process. *"You seem upset at the news of this diagnosis. I want you to go home and discuss this with your loved ones and come back when you feel ready to make a plan together for your care."* - While acknowledging distress, sending the patient home without further engagement **delays urgent care** for small cell lung cancer, which is aggressive. - This response might be perceived as dismissive of his immediate feelings and can **exacerbate his sense of hopelessness** and isolation. *"It must be tough having received this diagnosis; however, new cancer therapies show increased efficacy and excellent outcomes."* - This statement moves too quickly to treatment efficacy without adequately addressing the patient's current **emotional state and fatalism**. - While factual, it **lacks empathy** for his personal feelings of blame and hopelessness, potentially making him feel unheard. *"We are going to need to treat your lung cancer. I am here to help you throughout the process."* - This response is **too directive and authoritarian**, which can alienate a patient who is already feeling guilty and resistant to treatment. - It fails to acknowledge his stated feelings of "no hope now" or his disinterest in treatment, which are critical to address before discussing the necessity of treatment. *"I respect your decision and we will not administer any treatment. Let me know if I can help in any way."* - While respecting patient autonomy is vital, immediately accepting a patient's decision to refuse treatment without exploring the underlying reasons (e.g., guilt, hopelessness, lack of information) is **premature and potentially harmful**. - The physician has a responsibility to ensure the patient is making an informed decision, especially for a rapidly progressing condition like small cell lung cancer.

Question 8: A 69-year-old woman with acute myeloid leukemia comes to the physician to discuss future treatment plans. She expresses interest in learning more about an experimental therapy being offered for her condition. After the physician explains the mechanism of the drug and describes the risks and benefits, the patient then states that she is not ready to die. When the physician asks her what her understanding of the therapy is, she responds "I don't remember the details, but I just know that I definitely want to try it, because I don't want to die." Which of the following ethical principles is compromised in this physician's interaction with the patient?

A. Patient competence
B. Patient autonomy
C. Decision-making capacity (Correct Answer)
D. Information disclosure
E. Therapeutic privilege

Explanation: ***Decision-making capacity*** - This refers to a patient's ability to **understand information relevant to a medical decision**, appreciate their situation, reason through options, and communicate a choice. The patient's statement indicates a lack of understanding of the details of the complex treatment, despite being explained. - While she expresses a choice, her inability to recall details suggests she cannot adequately **weigh risks and benefits**, which is central to capacity. *Patient competence* - **Competence is a legal determination** made by a court, not by a physician in a clinical setting. - Physicians assess **decision-making capacity**, which is a clinical judgment, whereas legal competence has broader implications. *Patient autonomy* - **Autonomy is the right of a patient to make their own choices** about their medical care. While the patient is attempting to exercise a choice, the issue here is whether she is able to make an adequately informed choice. - For autonomy to be truly upheld, the patient must have the **capacity to make an informed decision**, which is compromised by her stated lack of understanding. *Information disclosure* - The physician *did* disclose information about the drug's mechanism, risks, and benefits, indicating that the act of disclosure itself was performed. - The problem is not that information was withheld, but that the patient **did not retain or understand the disclosed information** sufficiently. *Therapeutic privilege* - **Therapeutic privilege** is when a physician withholds information from a patient if they believe the disclosure would cause significant harm. - In this scenario, the physician *did* explain the treatment, so information was not withheld under privilege.

Question 9: A 72-year-old man is seen in the hospital for a sacral rash. The patient has been hospitalized for the past 3 weeks for a heart failure exacerbation. When the nurse went to bathe him this morning, she noticed a red rash over his sacrum. The patient reports mild discomfort and denies pruritus. The patient has chronic kidney disease, urinary incontinence, ischemic cardiomyopathy, gout, and poor mobility. His current medications include aspirin, furosemide, metoprolol, lisinopril, spironolactone, and prednisone that was started for a recent gout flare. The patient’s temperature is 97°F (37.2°C), blood pressure is 110/62 mmHg, pulse is 68/min, and respirations are 13/min with an oxygen saturation of 98% on room air. On physical examination, there is a 4 cm x 6 cm patch of non-blanchable erythema over the patient’s sacrum that is mildly tender to palpation. Labs are obtained, as shown below: Leukocyte count: 10,000/mm^3 with normal differential Hemoglobin: 15.2 g/dL Platelet count: 400,000/mm^3 Serum: Na: 138 mEq/L K+: 4.3 mEq/L Cl-: 104 mEq/L HCO3-: 25 mEq/L BUN: 26 mg/dL Creatinine: 1.5 mg/dL Glucose: 185 mg/dL A hemoglobin A1c is pending. Which of the following is the best management for the patient’s most likely diagnosis?

A. Surgical debridement
B. Repositioning (Correct Answer)
C. Topical silver sulfadiazine
D. Metformin
E. Prophylactic oral ciprofloxacin

Explanation: ***Repositioning*** - The patient's presentation of a **non-blanchable erythematous rash** over the sacrum in a bedridden patient indicates a **Stage 1 pressure injury**. - **Repositioning** is the cornerstone of management for preventing progression and promoting healing of pressure injuries by relieving pressure on affected areas. *Surgical debridement* - This is typically reserved for **Stage 3 or 4 pressure ulcers** with significant tissue necrosis or infection, which is not present in a Stage 1 injury. - Debridement would be unnecessary and potentially harmful for an intact, non-infected area of non-blanchable erythema. *Topical silver sulfadiazine* - This is an **antimicrobial cream** used for burn wounds and infected ulcers. - It is not indicated for a Stage 1 pressure injury, which is characterized by intact skin without infection or open wounds. *Metformin* - **Metformin** is an oral hypoglycemic agent used to manage type 2 diabetes. - While the patient's elevated glucose and pending HbA1c suggest potential diabetes or stress hyperglycemia, metformin does not directly address the sacral rash. *Prophylactic oral ciprofloxacin* - **Prophylactic antibiotics** are generally not indicated for Stage 1 pressure injuries, as there is no evidence of infection. - Unnecessary antibiotic use can contribute to **antibiotic resistance** and potential side effects.

Question 10: A patient was referred by a doctor to a radiologist for a CT scan and the doctor was given money for the referral. What is this unethical act called?

A. Criminal negligence
B. Commission
C. Medical maloccurrence
D. Fee splitting (Correct Answer)
E. Dichotomy

Explanation: ***Fee splitting*** - **Fee splitting** occurs when a healthcare provider (e.g., a doctor) receives payment for referring a patient to another healthcare provider or service (e.g., a radiologist). - This practice is considered unethical and often illegal because it creates a financial incentive for referrals, potentially leading to unnecessary services or choices not based on the patient's best interest. *Criminal negligence* - **Criminal negligence** involves a reckless disregard for the safety of others, leading to harm, often in situations where a duty of care was owed. - It is characterized by actions or inactions that demonstrate a gross deviation from the standard of care, resulting in injury or death, which is not the case in this scenario. *Commission* - In a medical context, **commission** generally refers to an action taken by a healthcare provider. While the act of referring a patient is a commission, it does not specifically define the unethical monetary exchange. - The term "commission" alone does not convey the unethical nature of receiving money for a referral. *Dichotomy* - **Dichotomy** in medical ethics refers to the division of fees between two healthcare providers for services actually rendered (e.g., a surgeon and assistant surgeon splitting a surgical fee). - While also ethically questionable in many contexts, dichotomy involves splitting fees for work performed, whereas fee splitting involves payment specifically for making a referral without providing additional services. *Medical maloccurrence* - **Medical maloccurrence** is a broad term that refers to an untoward event or bad outcome that occurs during medical care but does not necessarily imply negligence or wrongdoing. - It describes an adverse event that may happen despite appropriate care, which is distinct from an unethical financial arrangement.

Want unlimited practice?

Get full access to all questions, explanations, and performance tracking.

Start For Free