Behavioral Science notes for USMLE Step 1

Autonomy

  • Patient has rights to make decisions regarding his/her treatment
  • The wishes have to be carried out even in the event that he/she loses consciousness
  • Out of beneficence (doing what is good) & autonomy, autonomy is more important
  • Confidentiality is violated only if patient has TB, HIV, STD, or other conditions which can harm innocent third-party

Consent

  • Consent needs to be taken for providing all kinds of medical care
  • Consent required from parents if patient is a minor (<18)
  • But in life-threatening situations, blood transfuions & surgery can be done (implied consent)

Partial Emancipation

  • In areas of STD, contraception, prenatal care, substance abuse consent from parents is not needed if patient is above 15 years of age (mature minor)

Emancipated Minor

  • A small number of minors at age of 16 or 17 (varies from state to state), who are married, self-supporting, living independently, or themselves have a child that they support or in the military do not need parental consent but legal permission maybe required for serious medical conditions or surgery (such as organ donation)
  • Parents can’t refuse any treatment for their children on religious beliefs in life-threatening conditions (for example blood transfusions), even if the child is severely brain-damaged or developmentally disabled
  • Parents can refuse treatment only if child’s disease is incompatible with life
  • A patient with mental illness, mental retardation, autism (even with mental age of 8) that might be considered incompetent for other areas of life still has the right to refuse for medical procedures (power of autonomy over beneficence)

Informed Consent

  • For each & every procedure
  • No procedure or surgery to be extended even if it is in patients favor (autonomy)
  • Decisions (oral or written) made when patient was competent and conscious are valid even when patient loses capacity later on to make decisions
  • Oral consent valid for all procedures (even heart transplant) but difficult to prove if need arises
  • Consent is implied in emergency
  • Consent over telephone is valid but you need a witness and make sure you take consent from right person
  • Information about the patient cannot be released if the patient does not sign the release form
  • If court of law enforcement agency wants any such information it can only be disclosed if they have a valid court order and a search warrant

End of Life Issues

Advanced Directive

  • Is a method by which a parents communicates his/her wishes for healthcare in advance before becoming unable to make decisions for his/herself
  • Advanced directives could be a living will or healthcare proxy
  • Living will is a document in which a patient expresses his/her wishes in written form
  • Healthcare proxy (medical power of attorney) is a patient assigned person who speaks on behalf of the patient
  • In case their is no living will or healthcare proxy and the patient does not have the capacity to make decisions first we ask the spouse of the patient regarding what the patient would have wished for him/herself. The next assigned proxy are the parents or children of the patient.
  • In case the family members disagree about the treatment decisions you should take the following steps in sequence
    1. Encourage consensus and request discussion among family members to reach a decision
    2. Refer to hospital ethics committee
    3. Refer to court or seek judicial intervention

Terminally-ill Patients

  • Physician assisted suicide and euthanasia are unacceptable and unethical
  • Law of double effect is when the treatment offered to relieve discomfort can shorten the life of the patient, then the prime duty is to relieve pain even if it shortens the patients life. For example opiods can be given to a patient with known COPD who is terminally-ill and is in excruciating pain

Futile Care

  • Physician is not under obligation to give treatment that will not benefit the patient even if the patient or family is demanding it
  • Brain-dead means the patient is dead even if the heart is beating. You can take off ventilatorly support (need no permission) but before turning off the ventilator its advisable to explain to the family members the meaning of brain-dead and obtain consensus.

Organ Donation

  • Organs can be removed even when the heart is beating, in fact it is better because the organs are well perfused
  • Physicians should never obtain consent for donation, only the organ donor network should obtain the consent
  • Even if the patient has an organ donor card family consent is still necessary

Ethical Dilemmas

  • Informed refusal is as important as informed consent
  • A psychiatrist and his/her patient can never have a sexual relationship even if the physician-patient relationship is terminated.
  • Child-abuse reporting is mandatory
  • Impaired driver (history of seizures or vision loss) should report him/herself to DMV first. If on persistent counseling he/she does not report by him/herself you may have to report to DMV.
  • Spousal abuse cannot be reported without consent
  • Do not disclose genetic information to the employer unless the patient wants that
  • Risk-management is the term applied to the portion of hospital administration that evaluates potential legal liability to the institution

 

 

 

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