Case regarding informing the patient or family first of any bad news...

You are discussing the care of an elderly woman with her family.Although she is awake and alert, the patient is very ill and physically fragile.You area waiting the results of a biopsy for what will likely be cancer which has already metastasized through out the body.The family asks that you inform them first about the results of the biopsy.They are very loving and caring and are constantly surrounding the Patient. They do not want to depress the patient further,and because there will be no hope for a cure they see no reason to ruin her remaining life with this information.

What should you tell them?

a. You will honor their wishes.

b. You agree with their wishes and you ask them to give you the necessary written request.

c. You ask them to involve the ethics committee for the hospital.

d. You tell them that you are obligated to inform the patient of all the findings.

e. Explain to them that that decision can only be made  y the health-care proxy.

Answer:

Breaking Of Confidentiality In Order To Prevent Injury To Others

You are a psychiatrist in session with a patient who tells y u he thinks his boss at work is persecuting him. The patient has had mild schizophrenia. The patient asks you if you can keep a secret and then tells you that he is planning to kill his boss "when the time is right." You say," Of course, every thing you tell me during the session will always be confidential."

What should you do?

a. Keep the patient's session confidential but make attempts to discourage the patient from his plan.

b. Inform your medical director and let him handle it.

c. Inform law enforcement agencies of the threat to the patient's boss.

d. Inform the patient's boss that he is in danger.

e. Inform both the patient's boss as well as law enforcement of the threat.

Answer:

Confidentiality Issues In Medical practice

You are seeing patients in clinic when two men in dark suits and dark glasses come in and show you badges marking them as members of a federal law enforcement agency. The identification is legitimate. These  'men in black' inform you that they are making a "minor investigation" of one of your patients. They ask to look at the patient's chart for a few minutes, saying, "You wouldn't want to interfere with a federal investigation, would you?"

What should you do?

a. Give them the chart.

b. Give them the chart but watch what they do with it.

c. Ask them to sign a release for the chart so you are  absolved of responsibility.

d. Tell them you cannot show them the chart unless there is a signed release from the patient.

e. Tell them that you can give copies but not the original record.

f. Don't give them the chart but read the relevant information to them.

Answer:

Confidentiality In Medical Ethics

You are working at the desk in your hospital when another employee of the hospital asks for information about a patient who was admitted last night with a pulmonary embolus secondary to cancer. You know the details of the case. The person requesting the information states that he is a close friend and coworker of your patient. He shows you proper identification proving he really is a coworker of your patient who also works in the hospital.

Which of the following is the most appropriate response to this request?

A. Give him the information on the patient.
B. Give him the information only if he is a relative of the patient.
C. Inform him that you are not at liberty to give details regarding the patient without the patient's permission.
D. Have him sign a release or consent form before revealing the information.

Answer:

Components Of An Informed Consent Before Performing Any Procedure

All of the following are part of the informed consent process EXCEPT:
A. Alternatives and likely consequences of the alternatives to the procedure
B. Ascertainment of understanding by the patient
C. Discussion of the details of the procedure
D. Outlining the patient’s wishes if he or she becomes unable to make decisions
E. Risks and benefits of the procedure

Answer:

Explanation to a patient of the need for investigations

Case Scenario: You are a junior doctor working on a cardiology ward. Mr  ABC, aged 23 years,
has congenital heart disease. He was admitted from clinic for further investigations into the cause of his breathlessness. The view of the cardiac team is that it will not be possible to give best advice about prognosis and treatment without information from a cardiac catheterisation study, but he is refusing to consent.

Your task: is to determine what concerns Mr ABC has and explain the purpose of further investigation.

Key issues to explore

• First find out what the patient knows about his condition: he may be concerned that nothing can be done or be in denial about the seriousness of the problem. 
• Then establish what he knows about cardiac catheterisation and his fears about the procedure: some patients are worried about pain and discomfort, whereas others worry about complications. Try and put any such fears in perspective.
• Explain any alternative investigative strategies that are available, but also why a cardiac catheterisation study is needed to give him best advice about his condition. 
• If possible offer him information booklets and if there is a specialist nurse available, ask him or her to speak with the patient.

Key points to establish
The patient does not have to undergo any investigation or treatment unless he agrees to it. He will still receive care even if he does not undergo the investigations recommended, but a proper investigation may improve the care that can be given to him and thus alleviate some of his symptoms.

Appropriate responses to likely questions

Patient: I feel fine.
Doctor: I hear what you say, but you went to the doctor because your breathing isn’t as good as it should be and it looks as though this is due to a problem with your heart.

Explanation to a patient who is reluctant to receive treatment

Case Scenario: You are a junior doctor in a medical outpatient clinic. A 30 year old female who has come for a prescription of an oral contraceptive pills is found to have high blood pressure. Her BP has been measured on several occasions and found to be consistently in the region of 180/100 mmHg. It has been explained to her that she has high BP that requires investigation and treatment, but she feels well and only wants a prescription for the oral contraceptive pill, not any tests or medication.
Your task is to inform the patient why investigations and treatment are required.

Key issues to explore
The key to a successful outpatient consultation will be to understand the reason why the patient does not want further investigation or treatment.

• Does she feel that investigation and treatment are unnecessary because she feels well?
• Is she afraid of what may be found?
• Is she concerned about the effects of treatment?

Key points to establish

• It is very important to establish a rapport with this woman so that she will trust you and thus hopefully follow the recommended management plan. 
• Explain to her that hypertension is a common and often asymptomatic condition that is frequently detected on routine screening, or incidentally as part of investigations for other medical problems. 
• It is important that she understands what hypertension is and why it should be taken seriously, even in the absence of  any complaints or limitations: the potential harmful effects of long term high BP must be explained.
• She will need reassurance and an explanation that investigations are necessary to exclude a secondary cause of high BP, which might mean that the hypertension can be cured and that she would not need long term treatment. 
• If no specific cause for hypertension is found, then simple changes to her lifestyle may be adequate to treat her BP. But in some situations this is not enough and she may require medication.
• Your advice should be accompanied by provision of reading material and help with associated programmes for smoking cessation, weight loss and dietary advice.

Appropriate responses to likely questions

Advising A Patient Against Unnecessary Investigations

Case Scenario: You are a junior doctor in a cardiology outpatient clinic when a 28 years old female comes for investigation of palpitations. She had previously not been worried about these symptoms,
but recent knowledge of the deaths of two relatives following sudden collapses has made her very concerned. At her first appointment it became clear from her history that the palpitations were consistent with ventricular ectopic beats.
Examination was normal, as was a routine 12-lead ECG.
Echocardiography showed her heart to be normal and a 24-hour  ECG demonstrated ectopic beats when she was symptomatic.
She is keen to have further investigations, but these would not be appropriate.
Your task is to reassure the patient that her condition is benign and explain that further investigations are not necessary.

Key issues to explore: 

• What is the patient’s main concern? 
• Why does she want further investigation? 
• Does her desire stem from the actual symptoms or the perceived risk from the condition in view of her family history?

Key points to establish:

• Reassure the patient that the diagnosis of ectopics is certain, as her symptoms have been clearly correlated with ectopics on the 24-hour ECG. 

Communicating News Of A Patient’s Death To A Spouse

Case Scenario: A 40-year-old man, is admitted from work with a large anterior myocardial infarct, which is treated with thrombolysis. Unfortunately he arrests and, despite prolonged attempts at resuscitation, he dies. His wife arrives 5 minutes after he dies. You are a junior doctor on a coronary care unit and your task is to inform the wife that his husband is dead.

How will you approach this case?

Key issues to explore: 
What does the patient’s wife know already?
She will be more prepared for bad news if she knows he is gravely ill than if she doesn’t know why he is in hospital. Explaining an unexpected death is one of the most difficult communication tasks that a medical professional has to perform: if it is done with compassion and sensitivity it can ease the inevitable distress that family and friends will go through.

Key points to establish And Steps In Communicating : 

1. Find a quiet room, if possible a relatives’ room, and ask the nurse looking after the patient to accompany you. 
2. Leave your pager with someone else so that you are free of interruptions. 
3. There is no hiding from the fact that you must inform the wife that her husband has had a heart attack and unfortunately has not survived.