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SocialSciencesMain21-29Q1A32~year-oldwomanat42weeksofgestationisadmittedtothelaboranddeliveryunitbecauseofincreasedfetalmovementanduterinecontractionsevery7minutes.Herbioodpressureis120/60mmHg,pulseis78/min:andrespirationsare12/min.Fetalheartmonitoringindicatesthatthefetusisinmilddistress.Anultrasoundconfirmsfetalmacrosomiaandfindingssuspiciousforoligohydramnios.Thepatientisinformedoftheneedforcesareansection.Sheistoldthatsheisatsignificantriskofperineallacerationwithvaginaldeliveryandthatthefetusisatriskforasphyxiaanddeathwithoutanemergentcesareansection.However,sherefusestoundergocesareansectionandinsistsonvaginaldelivery.Furtherdiscussionrevealsthatshefullyunderstandstherisksofrefusingtheprocedure,butinsistsonvagina!delivery.Whichofthefollowingisthemostappropriatenextstep?A.ProceedwithemergentcesareansectionbecausethereisevidenceoffetaldistressB.Proceedwithemergentcesareansectionbecausethefetus'rightsaremoreimportantthanthepatient'sautonomyC.Respectthepatient'sdecision,andproceedwithvaginaldeliveryD.SeekoutanalternativedecisionmakerwhowillmakebetterdecisionsE.eekacourtorderforcingthemothertoundergoemergentcesareansectionA1Correctanswer:CThispatientpresentswithpost-termpregnancy,definedasapregnancythatextendstoorbeyond42weeksgestation.Fetalrisksfrompost-termpregnancyincludeasphyxia,death,meconiumaspiration,andintrauterineinfection.Currentrecommendationsadviseemergentcesareansectioniftherearesignsoffetaldistressoroligohydramnios,asseeninthispatient.Otherwise,expectantmanagementwithvaginaldeliveryisanoptioninselectstablepatients.Inobstetrics,themedicaldecisionsmadebyonepatient(themother)candirectlyaffecttheoutcomeofanother(thefetus).Incertainsituations,suchasthisone,conflictcanarisebetweentheprinciplesofmaternalautonomyandtherightsofthefetusasaperson.Althoughtheethicalcodevariesfromcountrytocountry,IntheUnitedStates,themotherisconsideredtohaveultimaterightsoverherunbornchild,assumingshehascapacity.Whenamotherrefusesaprocedureortreatmentthatisinthebestinterestofthefetus,thephysicianshouldprovidecounselingandeducationastowhytheprocedureisnecessary.Ifthemothercontinuestorefuseaprocedurethatwouldpreventirreversibleharmtothefetus,thehospitalethicscommitteeshouldbeconsulted,butthemothershouldnotbecoercedorotherwiseforcedintoacceptinganyformoftreatmentshedoesnotwant.Althoughthispatient'swishesarenotInthebestinterestofherfetus,shehascapacityandisentitledtomakedecisionsthataffectherunbornchild.Shecannotbeforcedintoacceptinganinvasivecesareansection,evenifherchildmightsufferharm.Sheshouldbeadvisedoftherisksandlikelyconsequencesofvaginaldeliveryandtheneedforemergentcesareansection,butthephysicianmustrespectandcomplywithherfinaldecision.(ChoicesAandB)Becausethispatienthascapacityandherunbornchildisstillphysicallyattachedtoher,shecannotbeforcedtoundergotreatmentforthebenefitofherchild;herautonomysupersedestherightsoftheunbornchild.Therefore,itisunlawfultoproceedwiththecesareansectionagainstherwishes.(ChoiceD)Seekingoutanalternatedecisionmakersuchasaspouseoraparentwouldbemoreappropriateinsituationsinwhichthepatientlackedcapacity.However,asthepatientcurrentlyhascapacityandismakingadecisionwithawarenessoftherisksandbenefits,itisnotappropriatetoaskfamilymemberstomakemedicaldecisionsforthepatient.Ifthechild'sfatherIsinvolved,itwouldbeappropriatetoaskthepatienttodiscussheroptionswithhimpriortomakingthisdecision.(ChoiceE)Judicialinterventionshouldonlybeconsideredasalastresortinexceptionalcircumstances,suchaswhentherefusedtreatmentposesinsignificantrisktothemother,involvesminimalInvasionofherbodilyintegrity,andwouldpreventsubstantialandirrevocableharmtothefetus.Althoughcesareandeliverywouldalmostcertainlybenefitherunbornchild,itishighlyinvasiveandcarriessignificantmaternalrisks.Educationalobjective:Apregnantwomanwhohascapacityhastherighttorefusetreatment,evenifitplacesherunbornchildatrisk.Q2A28-year-oldmarriedwomanwhoworkswithyouintheclinicasanurseprivatelycomestoyoubecauseshemissedaperiodthismonth.Anover-the-counterurinepregnancytestconfirmsthatsheispregnant.First-trimesterlaboratorytestingrevealsthatsheisalsoHIVpositive.WhenyouinformthepatientofherHIVstatus,sheisdevastated.Shehesitantlyrevealsthatshehadunprotectedsexualintercoursewithaformerboyfriendseveralmonthsago.Youexplainthatherhusband'sHIVstatusmustbeevaluated.ThepatientishorrifiedandsaysNo.Icannottellhimaboutthis.Hewouldneverforgiveme!Whichofthefollowingisthemostappropriatefirststep?A.immediatelyinformthelocalhealthdepartmentB.ImmediatelyInformthelocalhealthdepartmentandthepatient'shusbandC.AssurethepatientthatherconditionwillbekeptabsolutelyconfidentialD.EncouragethepatienttotellherhusbandbuttellherthatyouarerequiredtoinformthelocalhealthdepartmentE.TellthepatientthatshecannotexpectyourmedicalormoralsupportifshedoesnottellherhusbandA2Correctanswer:DThispatientpresentswithaHIV-positivetestandwishesnottodiscussherresuitswithherhusband.TheHealthInsurancePortabilityandAccountabilityActallowspatientinformationtobeconfidential,butreportingofdiseasesthatareviewedaspublicheal