Informed consent

Informed consent US Medical PG Question 1: A 79-year-old male presents to your office for his annual flu shot. On physical exam you note several linear bruises on his back. Upon further questioning he denies abuse from his daughter and son-in-law, who live in the same house. The patient states he does not want this information shared with anyone. What is the most appropriate next step, paired with its justification?

• A. Breach patient confidentiality, as this patient's care should be discussed with the daughter as she is his primary caregiver
• B. See the patient back in 2 weeks and assess whether the patient's condition has improved, as his condition is not severe
• C. Do not break patient confidentiality, as elder abuse reporting is not mandatory
• D. Do not break patient confidentiality, as this would potentially worsen the situation
• E. Breach patient confidentiality, as this patient is a potential victim of elder abuse and reporting is mandated in most states (Correct Answer)

Informed consent Explanation: ***Breach patient confidentiality, as this patient is a potential victim of elder abuse and reporting is mandated in most states*** - As a physician, there is a **legal and ethical obligation** to report suspected elder abuse in most US states, even when the patient denies it and requests confidentiality. - Physicians are typically **mandatory reporters** under state law, and must report to Adult Protective Services or law enforcement when elder abuse is suspected. - The patient's safety and legal requirements outweigh the right to confidentiality in jurisdictions with mandatory reporting laws. *Breach patient confidentiality, as this patient's care should be discussed with the daughter as she is his primary caregiver* - Breaching confidentiality to discuss this with the daughter would be inappropriate, especially since the daughter and son-in-law are the **suspected abusers**. - Discussing with the primary caregiver is only appropriate if the patient has given **explicit consent** and there are no suspicions of abuse from that caregiver. *See the patient back in 2 weeks and assess whether the patient's condition has improved, as his condition is not severe* - This option is inappropriate because it delays intervention in a potentially **dangerous situation**. - Suspected abuse warrants **immediate action** to ensure the patient's safety, regardless of the perceived severity of current injuries. *Do not break patient confidentiality, as elder abuse reporting is not mandatory* - In **most states**, physicians have **mandatory reporting laws** for elder abuse, making this statement generally incorrect. - Physicians are typically considered "mandated reporters" and are legally required to report suspected abuse to the appropriate authorities in their jurisdiction. *Do not break patient confidentiality, as this would potentially worsen the situation* - While this is a valid concern in some situations, the **primary responsibility** of a physician is to protect vulnerable patients from harm. - Reporting suspected abuse initiates protective measures and is legally required in most states, as the potential benefit of intervention outweighs the risk of worsening the situation.

Informed consent US Medical PG 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

Informed consent 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.

Informed consent US Medical PG Question 3: 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

Informed consent 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.

Informed consent US Medical PG Question 4: A 19-year-old man presents to an orthopedic surgeon to discuss repair of his torn anterior cruciate ligament. He suffered the injury during a college basketball game 1 week ago and has been using a knee immobilizer since the accident. His past medical history is significant for an emergency appendectomy when he was 12 years of age. At that time, he said that he never wanted to have surgery again. At this visit, the physician explains the procedure to him in detail including potential risks and complications. The patient acknowledges and communicates his understanding of both the diagnosis as well as the surgery and decides to proceed with the surgery in 3 weeks. Afterward, he signs a form giving consent for the operation. Which of the following statements is true about this patient?

• A. He cannot provide consent because he lacks capacity
• B. He has the right to revoke his consent at any time (Correct Answer)
• C. His parents also need to give consent to this operation
• D. He did not need to provide consent for this procedure since it is obviously beneficial
• E. His consent is invalid because his decision is not stable over time

Informed consent Explanation: ***He has the right to revoke his consent at any time*** - **Informed consent** for medical procedures is an ongoing process, and a patient retains the right to **withdraw consent** at any point, even after initially signing the consent form. - This right is a fundamental aspect of patient autonomy and ensures that medical interventions are only performed with a patient's current and willing agreement. *He cannot provide consent because he lacks capacity* - The patient is 19 years old, which in most jurisdictions (including the US where the age of majority is typically 18) means he is considered an **adult** and legally capable of providing his own consent. - The scenario explicitly states he "communicates his understanding of both the diagnosis as well as the surgery," indicating he possesses the **mental capacity** to make an informed decision. *His parents also need to give consent to this operation* - As a 19-year-old, the patient has reached the **age of majority** and is legally entitled to make his own medical decisions, including consenting to surgery. - Parental consent is generally required for minors (individuals under the age of majority), but not for adults like this patient. *He did not need to provide consent for this procedure since it is obviously beneficial* - Even for procedures that are clearly **beneficial**, informed consent is ethically and legally mandatory to uphold **patient autonomy** and ensure respect for individual rights. - The concept of "obviously beneficial" does not negate the requirement for a patient's explicit agreement to a medical intervention. *His consent is invalid because his decision is not stable over time* - While the patient might have initially hated surgery at age 12, his current decision at age 19 to proceed with the ACL repair is based on current information and his mature understanding. - The fact that his previous aversion to surgery has changed does not invalidate his current, well-informed decision; it simply indicates a change in perspective based on new circumstances and greater maturity.

Informed consent US Medical PG Question 5: 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

Informed consent 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.

Informed consent Flashcard 1 of 5

Question: SVC syndrome can be caused by _____ from indwelling central venous catheters

Answer: thromboemboli

Informed consent Flashcard 2 of 5

Question: Give four common exceptions to informed consent.

Answer: 1 - legally incompetent 2 - implied consent in emergency 3 - patient waiver 4 - therapuetic privilege (disclosure could harm the patient)

Informed consent Flashcard 3 of 5

Question: What are the three procedural requirements for informed consent? (i.e. steps that must be taken, not characteristics of the patient.)

Answer: 1 - discussion of pertinent info 2 - agreement to plan 3 - freedom from coercion

Informed consent Flashcard 4 of 5

Question: Legal exceptions for parental consent include: (1) - _____ treatment (2) - if the minor is legally emancipated

Answer: emergency

Extra Information: Watch associated Bootcamp video [https://app.bootcamp.com/med-school/public-health-sciences/videos/ethics?index=3] https://onlinemeded.org?ref=anki 

Informed consent Flashcard 5 of 5

Question: When presented with a wound, consideration for tetanus vaccination begins with determining whether _____ lifetime doses have been given or not.

Answer: three

Extra Information:  https://onlinemeded.org/spa/pediatrics/vaccinations/acquire?ref=anki