An elderly female who has been your patient for several years is discovered lying on the floor of her kitchen by a Meals-on-Wheels volunteer. She is transported to the hospital in an unresponsive state. After a thorough evaluation, you diagnose a massive cerebral infarct. On several previous occasions the patient verbalized to you her desire to not be subjected to life-prolonging treatments should she ever be rendered incapacitated; however, she declined your suggestion to confirm this in writing. The patient is admitted to the hospital with “do not resuscitate” (DNR) orders and supportive measures are instituted. A neurology consultant evaluates her and agrees that her condition is terminal and irreversible. The patient’s nephew is angered by the DNR status and, noting that she has insurance coverage, demands every medical treatment that might prolong his aunt’s life, including resuscitation.
Which one of the following would be the best course of action in terms of legality and ethics?
Correct Answer D:
An adult patient or their legally authorized representative has the right to refuse any medical treatment, regardless of its likelihood of success; however, there is no legal right to receive any and all treatment demanded. When patients have explicit advance directives in writing, their wishes are clear. When no written document exists, but the patient’s desire is well known to his or her physician, the physician is ethically bound to honor these wishes. This responsibility must be balanced against the physician’s ethical obligation not to perform futile treatments of no benefit to the patient. A family member acting as a medical decision-making proxy is obligated to represent what they believe to be the patient’s wishes, even in the face of conflict with their personal beliefs.
This case highlights two commonly encountered issues: honoring the patient’s wishes when there is conflicting evidence of what their wishes may be, and withholding medically futile treatment. In this case, the futility of the patient’s condition overrides any confusion as to her wishes, and the admission treatment plan is the most appropriate. Naturally, it would be best to discuss this with the nephew and attempt to arrive at a consensus, with the patient’s best interest being the primary concern.
A 46-year-old woman comes to the emergency department because of respiratory distress. Chest x-ray film discloses patchy infiltration of the right lower lobe. The patient is diagnosed as having community-acquired pneumonia, and she is sent home with a prescription for erythromycin. The patient returns 2 days later complaining of new onset of swelling of her right leg and foot. Doppler studies show a proximal deep venous thrombosis in the right leg, and ventilation-perfusion lung scan is interpreted as high probability for a pulmonary embolus.
The care this patient received initially is best characterized as which of the following?
Correct Answer A:
Scenarios such as this are quite common in clinical medicine. Diagnostic errors and their study is a large field that occupies many people. The causes why physicians make diagnostic errors are legion, but many relate to “heuristic triggers” and failure to interpret new data in light of changing diagnostic hypotheses. This patient had many signs and symptoms suggestive of pneumonia. Some of these findings, such as the localized pleuritic chest pain, are not 100% specific. A more detailed history of the duration of symptoms and their rapidity of onset (rapid favors diagnosis of an embolism) would have been helpful.
Legal negligence like malpractice is a legal terms that reflects errors which occur outside the standard of accepted medical practice. Duty, breach, causation, damages are elements of a negligence action and such a determination can be made only by a judge. Malpractice specifically relates to care not within the accepted practice guidelines. There is no evidence from this vignette that the patient was misdiagnosed based upon practice outside this standard. She had signs and symptoms suggestive of pneumonia, a chest radiograph suggested pneumonia and she was given an antibiotic appropriate for community acquired pneumonia.
A 4-year-old boy is brought to the emergency department by his parents because of a swollen pinna. The father says that the boy fell off his tricycle in a playground. On physical examination the child's left ear is severely edematous and discolored. There is concern for the child because this is his third emergency department visit in the past 6 months. When discussing these concerns and the need for further evaluation with the parents, they become angry and want to take the child home now.
This case should be reported to the child protective service agency:
Correct Answer E:
There is no need for another physician to agree with your assessment. A single physician, social worker, or nurse can and must file a report with child protective services. There does not need to be a pattern of repeated suspicious injury or proof of parental abuse. The injury need not be life-threatening. The injury need only be strongly suggestive of abuse.
Even after informing the parents of the decision to report the case to the child protective services, they continue to deny having hurt the child and are furious.
If the diagnosis of child abuse is incorrect, the reporting physician is liable for:
The reporting physician is only liable if he does not report. The physician can be brought up on charges and suffer professional penalties only if he does not report. Civil and criminal charges may not be brought against the physician if the charge of abuse is incorrect. Likewise, his license may not be revoked, nor his medical society membership censured. The law aims to foster reporting of reasonable suspicions.
A 6-year-old child is brought into the emergency room by his father because of a fractured arm. Although his father states that the child fell off his bike, the fracture does not seem consistent with this story. On inspection, you discover that the child seems to have a number of old bruises on his back and on his legs, some of which seem reminiscent of finger markings.
Which of the following steps is not appropriate in this circumstance?
Child maltreatment is behavior toward a child that is outside the norms of conduct and entails substantial risk of causing physical or emotional harm. Four types of maltreatment are generally recognized: physical abuse, sexual abuse, emotional abuse (psychologic abuse), and neglect. The causes of child maltreatment are varied and not well understood. Abuse and neglect are often associated with physical injuries, delayed growth and development, and mental problems. Diagnosis is based on history and physical examination. Management includes documentation and treatment of any injuries and urgent physical and mental conditions, mandatory reporting to appropriate government or regulatory agency, and sometimes hospitalization or other steps such as foster care to keep the child safe.
Physicians who have reasonable grounds to suspect a child is in need of protection must report directly to a CAS (children’s aid society), and not rely on any other person to report on their behalf.
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