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USMLE Step 2 (Fach) / Ethics, Social Sciences (Lektion)
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- Hospice care - Focuson quality of life, not cure or life prolongation - Symptom control (pain, nausea, dyspnea, agitation, anxiety, depression) - Interdisciplinary team (medical, nursing, psychosocial, spiritual, bereavement care) - Services provided at home, assisted living facility, or dedicated facility - Requires survival prognosis of ≤ 6 months
- Surrogate decision-making The surrogate decision-maker may be appointed by patients (e.g., medical power of attorney), legally appointed (e.g., court-ordered guardian), or next of kin (if no advance directive exists). The exact hierarchy of decision-making generally follows the following order: 1. A mentally competent patient capable of expressing his/her own decision 2. Advance healthcare directive- Durable medical power of attorney: a document through which an individual designates a surrogate health care decision-maker in the event that he/she lacks decision-making capacity or competence- Living will: Should the durable medical POA and the living will be in conflict, the POA can override the living will only if such a decision is in line with the patient's most recently expressed wishes. 3. Next of kin1. Spouse2. Adult child3. Parent4. Adult sibling5. In about half of states: “close friend” 4. Ethics committee or legal consult
- Medical errors Regardless of the outcome of a treatment, a physician must inform the patient immediately if an error has occurred and disclose the nature of that error. If a physician believes that a colleague has committed an error in a patient's care, the physician should urge their colleague to report this error to the patient. If the colleague refuses, the physician should report this error via their hospital's or clinic's standard protocol. If the cause of an error is not immediately known, the physician should inform the patient and maintain contact while investigations are being carried out.
- Physician-aided death Physician-assisted suicide: When a physician supplies a patient with the means to end their own life (e.g., a physician provides a patient with a lethal doseof morphine that the patient then self-injects)- Illegal in most states Euthanasia: The active termination of a terminally ill patient's life by a physician to end suffering. (e.g., a physician injects a lethal dose of morphine).- Euthansia is illegal in the United States. Terminal sedation: - It is legal to adjust medical therapy accordingly to provide relief from pain and suffering in a patient with terminal illness, despite hastening the patient's dying process (e.g., increasing doses of morphine in a patient with metastatic cancer)- Legal and distinct from euthanasia in so far as the intent must be to relieve pain rather than bring about death, even though it may hasten the dying process.- Not an appropriate means of addressing primarily existential suffering, e.g., death anxiety.- Principle of double effect: An ethical principle that legitimizes an act of good intent despite causing serious harm (e.g. self defense homicide or terminal sedation).
- Futile treatment A physician is not ethically obligated to provide treatment if it is considered futile (inappropriate treatment), even if requested by the patient or surrogate. Treatment can be considered futile if:- There is no evidence for the effectiveness of treatment- If the intervention has previously failed- If last-line therapy is failing- If treatment will not fulfill the goals of care: E.g., an elderly patient has had a massive stroke and is comatose. She has been intubated and stationed in the ICU. While admitted, the patient has a massive myocardial infarction and their surrogate decision-maker requests cardiac catheterization. In this situation, treating the MI is highly unlikely to improve this patient's overall clinical condition.
- Organ tissue donation Contraindications (deceased donors):- Malignancy that is non-curable or metastatic- Sepsis in the donor- Transmissible spongiform encephalopathies (prion diseases such as Creutzfeldt-Jakob disease)- Cardiac arrest occurring before brain death- Poor organ function (e.g., patient died of acute renal failure, so kidneys would be refused)- Hypothermia- Patient > 80 years old- Prolonged organ ischemia (e.g., patient found deceased at home)Not absolute contraindications:- Low-grade, localized tumors without evidence of metastasis at the time of death- History of malignancy with a disease-free duration > 5 years- Hepatitis B or C infection- HIV infection- Hypertension, diabetes, and/or elderly patients Living donors:- Nonvital organs and tissues can be acquired from living donors (e.g., liver or bone marrow)- Prior to donation, donors must give full informed consent- Donors have the right to withdraw from donation at any time- Donors may select the recipient of their donation- Donors may not be paid for their donation, but can be reimbursed for associated costs (travel, food, lost wages, etc.)- A donor may engage in an “organ swap”
- Exceptions to confidentiality - The patient directly requests the physician to share information with another party (e.g., a family member or for insurance purposes) - The patient has a notifiable disease: In this case, a physician is legally permitted to notify only a public health official. Depending on the disease, the patient should be encouraged to inform any third parties that may have been infected (e.g., sexual partners). The physician does not, however, have the right to inform third parties without the patient's consent.→ The public health department is responsible for notifying third parties if the patient refuses to inform them - The patient poses a danger to him/herself or others (e.g., suicidal, impaired driver, homicidal) - Elder abuse and child maltreatment - The patient has suffered penetrating trauma from assault (e.g., a gunshot wound, stab wound) - The patient is a minor and care does not involve sexual or addiction medicine (see informed consent in minors)
- Domestic violence - Refers to any form of actual or threatened physical or emotional harm within a household, frequently used to by one person to maintain power over another. - Usually occurs between partners in a relationship, in which case it is more accurately called intimate partner violence - When a physician suspects domestic violence, they should privately speak with the affected patient, inquire further, and offer assistance. - Physicians are not legally permitted to report domestic violence without patient consent (unless the patient is incompetent e.g., mentally disabled, elderly, or a minor) - In cases where the patient refuses aid, a physician should reiterate their support of the patient and the availability of aid at any time.
- Physician-patient romantic relationships - Romantic relationships with current patients are always unethical and inappropriate - Romantic relationships with former patients are also inappropriate if:→ The physician has a position of influence from his/her previous professional experience with the former patient (e.g., details of emotions expressed in previous interactions with the patient)→ Less than one year has passed since the end of the patient-physician relationship - Should a physician feel that their actions may be perceived as sexual and/or lead to a romantic relationship with a current patient, the physician should take active measures to avoid unnecessary contact with the patient→ Use direct, close-ended questions→ Interview with a chaperone present
- Informed consent in minors A minor is any person < 18 years old in most states. Parental consent is required before a minor receives medical care, with a few exceptions:- The hospitalization or treatment is emergent and life-saving (e.g., trauma, suicidal ideation)- The minor is legally emancipated→ Granted via marriage, active military duty, or court petition.- The minor is seeking care regarding sex (contraception, pregnancy care, or STIs) or addiction care If parents refuse consent to treatment of a child for a non-emergent but fatal medical condition (e.g., bacterial meningitis, malignancy), the physician should first discuss this decision with the parents, then seek a court order mandating treatment if parents continue to refuse. A parent cannot refuse an emergently life-saving intervention for a minor (e.g., blood transfusion for hemorrhage), not even for religious reasons
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- Informed consent during pregnancy A pregnant woman has the right to refuse health care even if her decision poses a risk to the unborn fetus.
- Elder abuse Risk factors:- Female- Dementia, chronic mental illness- Functional impairments- Social isolation- Shared living environment- Poor socioeconomic status/financial stress Physical & sexual abuse:- Atypical abrasions, lacerations, contusions, fractures- Pain not consistent with reported etiology- Anogenital injuries- Newly acquired STI Psychological & verbal abuse:- Change in behavior/personality- Depression/anxiety Neglect:- Inadequate nutrition or hydration- Pressure injuries- Deterioration in comorbid conditions Financial exploitation:- Failure to adhere to medication regiment- Multiple missed appointments- Unpaid expenses or rent payments
- SPIKES protocol The SPIKES protocol is based on empirical data and guidelines and helps practitioners to break bad news to patients. S: SettingSetting up the interview and arranging for some privacy; involvement of significant others; avoidance of interruptions; providing information about the time frame of the interview to the patient P: PerceptionDetermination of the patient's perception of the situation; open-ended questions; patients are asked to explain illness/therapy/prognosis in their own words I: InvitationObtaining patient's invitation to talk about certain topics; offering opportunities to talk at a later point of time K: KnowledgeWarning the patient that bad news/prognosis is coming before giving knowledge and information; avoidance of technical terms; use of short and precise sentences; avoidance of excessive bluntness E: EmotionsIdentification of emotional triggers and addressing the patient's emotions with empathic responses (nonverbal communication) S: SummarySummary and strategy planning (treatment options, prognosis, next consultation, offering palliative support, inquiring about patient's needs and wishes)