Social-Sciences-Main社会医学-1-10

SocialSciencesMain1-10Q1A68-year-oldmartisbroughttothehospitaldueto2daysofprogressiveshortnessofbreathandcough.Hehasahistoryofseverechronicobstructivepulmonarydiseaseandhashadmultiplerecentexacerbationsandseveralhospitalizationsoverthepastyear.Duringhislasthospitalization,hehadacuterespiratoryfailurerequiringendotrachealintubation.Thispromptedthepatienttomakealivingwillspecifyingthathedoesnotwantanyresuscitativemeasuresorinvasivetherapiesintheeventofalife-threateningemergency.Onexamination,heislethargicandarousabieonlytonoxiousphysicalstimuli.Histemperatureis37.2℃(99℉)tbloodpressureis132/70mmHg，pulseis102/min,andrespirationsare32/min.Examinationrevealsdiffuselydecreasedbreathsounds,bilateralexpiratorywheezes,andlaboredbreathing.Itisdeterminedthathelacksdecision-makingcapacity.Hisdaughtersays,IhavebeentakingcareofmyfatherformanyyearsandIknowhimbetterthananyone.Hewouldnotwantanyaggressivemeasures.Pleasejustmakehimcomfortable.However,thepatient'swifedemandsthateverythingbedonetosaveherhusband'slife,includingintubationifnecessary.Sheinsiststhatsheknowswhatherhusbandwouldhavewantedandthreatenstofilealawsuit.Whichofthefollowinginterventionsisthemostappropriatenextstep?A.ConsultthehospitalethicscommitteeB.MeetwithallfamilymemberstoachieveconsensusonacourseofactionC.ObtainacourtordertoproceedwithintubationD.ProceedwithendotrachealintubationifmedicallyindicatedE.Respectthepatient'slivingwillandprovidecomfortcareonlyA1Correctanswer:EAlivingwill(advanceddirective)specifiesapatient'swishesforhealthcareinadvanceoflosingtheabilitytocommunicateorofbecomingincapableofmakinghisorherowndecisions.Inthiscase,thepatientisincapacitatedandhisfamilymembersstronglydisagreeonthebestcourseofaction;bothclaimtohaveabetterunderstandingofwhatthepatientwouldhavewantedinthecurrentsituation.However,thephysician'sresponsibilityistothepatient,andethicallythephysicianmustadheretothepatient'swishesasoutlinedinthelivingwill.Thelivingwillprotectsthepatient'sautonomyandoverrulesthewishesofanyfamilymembers.(ChoicesA,B,andC)Initiatingafamilymeetingwouldbethefirststepifthefamilymembersdisagreedaboutthecourseofactionandtherewasnolivingwilland/ornodesignatedhealthcareproxyinplace.Referraltothehospitalethicscommitteeorthecourtsforajudgmentwouldbecomenecessaryifnoconsensuswasachieved.(ChoiceD)ProceedingwithCPRorintubationwouldviolatethepatient'swishesasexpressedinhislivingwill.Educationalobjective:Alivingwillcommunicatesthepatient'sownwishesifheorshebecomesincapacitated,anditoverrulesthewishesofthefamily.Q2A44-year-oldpsychologyprofessorwithachronichistoryofrheumatoidarthritispresentsforafollow-upexamination.Sheiscurrentlytakingprednisoneandinfliximab,aregimenthathassuccessfullystabilisedhercondition.Physicalexaminationrevealsnosignificantchanges.Towardtheendofthevisit,shementionsthatshewouldliketotryacupunctureasanadjuncttreatmentinadditiontothemedicationssheiscurrentlytaking.Whatisthemostappropriateresponsetoherrequest?A.Imsorry,butIamnotveryfamiliarwithacupunctureandamreluctanttoucombinethetwotherapies.B.Ihopeyouareawarethatacupuncturehasitslimitations.C.Ifyouwanttotryacupuncture,1cannotcontinueservingasyourphysician.D.Whydoyouwanttotryacupuncture?E.Howcananeducatedwomanlikeyousuggestsomethinglikethis?A2Correctanswer:DAllpatientsenjoytherighttoselecttreatmentplansbasedontheirpersonalvaluesorpreferences.Whenapatientexpressesinterestinalternativemedicine,thephysicianshouldinquireaboutthereasonsfordepartingfromtraditionaltreatments.Itisimportanttodetermineifthepatientisdissatisfiedwiththequalityofhercurrentcareorifsheissufferingfromabothersomesideeffect.Therefore,itwouldbemostappropriatetoaskthispatientwhysheIsinterestedinacupunctureasanadjuncttreatment.(ChoiceA)Becausealternativemedicineisenjoyingincreasingpopularity,physicianshavetheobligationtobecomefamiliarwiththemostcommonlyusednon-traditionaltherapies,theirsideeffects,andanypotentialdruginteractions.Inthisinstance,thephysicianmustbepreparedtodiscussacupunctureandanycontraindicationsoradverseeffectswereittobeaddedtohertreatmentregimen.(ChoiceB)Thephysicianshouldencouragethepatienttoobtainrelevantliteratureandeducationalinformationaboutacupuncturefromreliablesources.Thisshouldnotberecommendedinanattempttoinstil!fearintothepatient,butinsteadtoenablethepatienttomakewell-informeddecisions.Ifthephysicianisalreadyawareofpotentiallyharmfulinteractions,thepatientshouldbetoldaboutthem.Thefirststep,however,Istodiscoverwhythepatientisinterestedinaddingthisalternativetherapytothetreatmentregimen.(ChoiceC)Thephysicianshouldnotabandonapatientwhoisinterestedinexploringanalternativetreatment.Instead,thepatient'spreferencesshouldberespectedandthepatientencouragedtolearnmoreabouttheavailableoptions.(ChoiceE)RidiculingthepatientforaninterestinalternativetherapywillInevitablyundermineallfuturedoctor-patientcommunication.Instead,physiciansshouldencouragepatientstokeeptheminformedaboutanyalternativetreatmentsundertaken.Physiciansshouldalsoseektoeducatethemselvesaboutthemorepopularalternativemedicinessothattheycanproperly