2 Item: 1 of 14 ljl f> Mark <::J t::>

:CJ5
Q. ld: 4953 [ Previous Next

A 35-year-old w oman is admitted to the hospital. She is 38 w eeks pregnant and experienced premature
rupture of membranes at home. The delivery is uneventful and the new born is doing w ell. How ever, the
6 patient complains of feeling exhausted from the delivery. She feels overwhelmed at the prospect of going
7 home to care for her new born and 2 other young children. Her insurance covers only a 2-day hospital
8 admission for an uncomplicated vaginal delivery. The patient requests that the physician "do something about
9 it" so that she can remain in the hospital for a few more days. W hich of the follow ing is the most appropriate
10
response?
11
12
r A. "Don't w orry. I'll call the insurance company and I'm sure they'll understand." [1 %]
:I ~~ I r B. "I am sorry that these are the insurance rules. I'll try, but I doubt extra days w ill be approved." [1 3%]
., r C. "I understand your concerns; however, insurance covers only extra days that are medically
necessary." [78%]
r D. "If you don't feel ready for discharge, I can w rite an order to lengthen your hospital stay." [7%]
r E. "Unfortunately, there is no point in trying. I can't misrepresent your condition." [1 %]

Explanation: User ld:

The physician should be sensitive to this patient's concerns about feeling overwhelmed, but should explain
that there is no medical reason to prolong the hospitaliz ation and that extra days w ould not be covered by
insurance. Efforts should be made to assist the mother by mobilizing family support and/or having social
w ork arrange for home services that might decrease the patient's sense of being overwhelmed.

(Choice A) Insurance rules are strict, and it is highly unlikely that extra days w ould be approved. Giving the
patient false reassurance that the insurance company w ould cover additional hospitalization is inappropriate.

(Choice B) Although it is important to acknow ledge and address the mother's concerns, attempting to justify
a medically unnecessary hospitalization is inappropriate. Arranging for additional support at home is a better
approach.

(Choice D) Extending the patient's hospitalization is inappropriate from a medical standpoint and w ould incur
a large non-covered medical expense for the patient.

(Choice E) This statement fails to acknow ledge the patient's concerns about not being ready to care for her
new born . She should be told that insurance covers hospitalization only w hen medically necessary and that
<'l ririitinn<'!l OIIIO<'!IiP.nt !':llnnort r.<'!n hP. <'!rr<'!nnP.ri if nP.r.P.!':!':<'Irv
 2 Item: 1 of 14 ljl f> Mark <::J t::>
:CJ5
Q. ld: 4953 [ Previous Next

r D. "If you don't feel ready for discharge, I can w rite an order to lengthen your hospital stay." [7%]
6 r E. "Unfortunately, there is no point in trying. I can't misrepresent your condition." [1 %]
7
8
Explanation: User ld:
9
10
The physician should be sensitive to this patient's concerns about feeling overwhelmed, but should explain
11
that there is no medical reason to prolong the hospitalization and that extra days w ould not be covered by
12 insurance. Efforts should be made to assist the mother by mobilizing family support and/or having social

:I ~~ I w ork arrange for home services that might decrease the patient's sense of being overwhelmed.

(Choice A) Insurance rules are strict, and it is highly unlikely that extra days w ould be approved. Giving the
patient false reassurance that the insurance company w ould cover additional hospitalization is inappropriate.

(Choice B) Although it is important to acknow ledge and address the mother's concerns, attempting to justify
a medically unnecessary hospitalization is inappropriate. Arranging for additional support at home is a better
approach .

(Choice D) Extending the patient's hospitalization is inappropriate from a medical standpoint and w ould incur
a large non-covered medical expense for the patient.

(Choice E) This statement fails to acknow ledge the patient's concerns about not being ready to care for her
new born . She should be told that insurance covers hospitalization only w hen medically necessary and that
additional outpatient support can be arranged if necessary.

Educational objective:
Insurance rules require that hospital level of care be justified as medically necessary; extended hospitalization
for other reasons is unlikely to be covered. The physician can assist the patient in understanding these
limitations and arrange for appropriate outpatient care.

References:
1. A basic concept in the clinical ethics of managed care: physicians and institutions as
economically disciplined moral co-fiduciaries of populations of patients.

Time Spent: 1 seconds Copyright USMLEW orld,LLC. l ast updated: [6/ 11/2014]
 1
ltem:2of14 ljl f> Mark <::J t::>
1tr5
6
Q. ld: 6326 [ Previous Next

A 60-year-old male patient of yours has a history of three m yocardial infarctions and a low ejection fraction
7 secondary to ischemic cardiom yopathy. He is currently being admitted for end-stage heart failure and has
8 been given a left ventricular assistance device on w hich he is dependent. Fortunately, the patient has no other
9 medical conditions and meets the criteria for heart transplant. He w as recently seen by a psychiatrist for w hat
10 he said w as erectile dysfunction. How ever, further review of his records and a consultation w ith his treating
11 psychiatrist reveal that the patient has recently been diagnosed w ith a major depressive disorder and that he
12 has an unstable home life. W hat do these findings mean regarding his ability to receive the heart transplant?

:I ~~ I r A. These findings cannot be considered in the decision to offer this patient a transplant [23%]
r B. These findings exclude the patient from transplantation [3%]
.; r C. These findings necessitate investigation and treatment before transplantation [71%]
r D. These findings predict a better outcome for the patient after transplantation [2%]
r E. These findings suggest that the left ventricular assistance device should be removed [1 %]

Explanation: User ld:

Mood disorders and a troubled home life in possible transplant recipients are major issues that may
predispose patients to poor outcomes after surgery. Mood disorders, how ever, are potentially treatable
psychiatric conditions, and their mere presence does not prevent a potential candidate from heart
transplantation. Psychiatrists are unable to predict future behavior w ith much accuracy, and data about
patients not able to receive transplantation is limited because they generally expire before such long term data
is collected. At best, physicians and organ transplant teams can merely consider these findings in the same
w ay they consider all other findings w hen assessing a patient for transplantation.

This patient should be fully evaluated and treated by a psychiatrist before he receives the heart transplant.

(Choice A) These findings cannot be ignored and must be considered as part of the transplant evaluation.

(Choice B) The presence of a mood disorder and a troubled home life in and of themselves w ould not
necessarily exclude this patient from transplantation.

(Choice D) Mood disorders and a poorly functioning family unit w ould most likely predict a w orse outcome for
the oatient after transolantation.
 1
ltem:2of14 ljl f> Mark <::J t::>
1tr5
6
Q. ld: 6326 [

r
r
Previous Next

A. These findings cannot be considered in the decision to offer this patient a transplant [23%]
B. These findings exclude the patient from transplantation [3%]
7 .; r C. These findings necessitate investigation and treatment before transplantation [71%]
8 r D. These findings predict a better outcome for the patient after transplantation [2%]
9
10 r E. These findings suggest that the left ventricular assistance device should be removed [1 %]
11
12
Explanation: User ld:

:I ~~ I Mood disorders and a troubled home life in possible transplant recipients are major issues that may
predispose patients to poor outcomes after surgery. Mood disorders, how ever, are potentially treatable
psychiatric conditions, and their mere presence does not prevent a potential candidate from heart
transplantation. Psychiatrists are unable to predict future behavior w ith much accuracy, and data about
patients not able to receive transplantation is limited because they generally expire before such long term data
is collected. At best, physicians and organ transplant teams can merely consider these findings in the same
w ay they consider all other findings w hen assessing a patient for transplantation.

This patient should be fully evaluated and treated by a psychiatrist before he receives the heart transplant.

(Choice A) These findings cannot be ignored and must be considered as part of the transplant evaluation.

(Choice B) The presence of a mood disorder and a troubled home life in and of themselves w ould not
necessarily exclude this patient from transplantation.

(Choice D) Mood disorders and a poorly functioning family unit w ould most likely predict a w orse outcome for
the patient after transplantation.

(Choice E) Removing the assist device w ould likely result in the patient's death . Once the device is placed, it
should not be removed because of a treatable mood disorder.

Educational objective:
Potential transplant recipients w ith mood disturbances and a poor home life can present a challenge to the
organ transplant team . These problems must be considered along w ith the rest of the information available
w hen contemplating a patient's suitability for organ transplantation.

Time Spent: 1 seconds Copyright USMLEWorld,LLC. Last updated: [7/ 1/2014]

 1
2 ltem:3of14 ljl f> Mark <::J t::>
Q. ld: 5052 [ Previous Next

~ 5
6
The follow ing vignette applies to the next 2 items
7
8 You are taking care of a 65-year-old male patient in the intensive care unit. The patient had an unw itnessed,
9 out-of-hospital cardiac arrest two days ago. He w as intubated and successfully resuscitated after a prolonged
10 CPR in the field. Tw o days later, he remains intubated, and relies on full ventilator support. He
11 is unresponsive to verbal and tactile stimuli. His temperature is 37.2 C (99 F), blood pressure is 110/70
12 mmHg, and pulse is 70/min. After a lengthy discussion w ith the patient's family, you all agree to have the
patient's life-sustaining support w ithdrawn.
:I ~~ I Item 1 of 2

W hich of the follow ing w ill you document to determine that the patient meets the criteria for brain death?

r A. Absence of respiratory drive for 5 minutes off the ventilator [18%]

r B. Body temperature below 35 C [1 %]
r C. EEG w ith nonspecific w aveforms [7%]
r D. Intermittent cerebral circulation on cerebral doppler scanning [1 %]
., r E. Irreversible absence of cerebral and brainstem reflexes [71 %]

Explanation: User ld:

Brain death is defined as the cessation of cerebral and brain stem function. A person is considered legally
dead in the United States w hen criteria for brain death have been demonstrated. One of the criteria to
determine brain death is the irreversible absence of cerebral and brainstem reflexes including pupillary,
oculocephalic, oculovestibular (caloric), corneal, gag, sucking, sw allow ing, and extensor posturing. Some of
the other criteria for determination of brain death include:

1. Absence of respiratory drive (apnea) off the ventilator for a duration that is sufficient to produce hypercarbic
drive (usually 10 to 20 minutes to achieve pC02 of 50 to 60 mmHg) (Choice A).
2. Body temperature below 34 C (93.2 F) (Choice B).
3. EEG isoelectric for 30 minutes at maximal gain (Choice C).
4. Absence of cerebral circulation by Doppler or magnetic resonance angiography (Choice D).
5. At least 24 hours of observation in adults w ith anoxic-ischemic brain damage w ith a negative drug screen
 1
2 ltem:3of14 ljl f> Mark <::J t::>
Q. ld: 5052 [ Previous Next

~ 5
V I 1 \. Ill liiC IICIU . I ~V V u a y ~ IOl CI ) IIC ICIIIOIII~ llllUU O l CU ) OII U ICIIC~

is unresponsive to verbal and tactile stimuli. His temperature is 37.2 C (99 F), blood pressure is 11 0/70
V II lUll V CIIUIOlVI ::.UtJtJ V I l. I IC

mmHg, and pulse is 70/min. After a lengthy discussion w ith the patient's family, you all agree to have the
6
patient's life-sustaining support w ithdrawn.
7
8
Item 1 of 2
9
10 W hich of the follow ing w ill you document to determine that the patient meets the criteria for brain death?
11
12
r A. Absence of respiratory drive for 5 minutes off the ventilator [18%]
:I ~~ I r B. Body temperature below 35 C [1 %]
r C. EEG w ith nonspecific w aveforms [7%]
r D. Intermittent cerebral circulation on cerebral doppler scanning [1 %]
., r E. Irreversible absence of cerebral and brainstem reflexes [71 %]

Explanation: User ld:

Brain death is defined as the cessation of cerebral and brain stem function. A person is considered legally
dead in the United States w hen criteria for brain death have been demonstrated. One of the criteria to
determine brain death is the irreversible absence of cerebral and brainstem reflexes including pupillary,
oculocephalic, oculovestibular (caloric), corneal, gag, sucking, sw allow ing, and extensor posturing. Some of
the other criteria for determination of brain death include:

1. Absence of respiratory drive (apnea) off the ventilator for a duration that is sufficient to produce hypercarbic
drive (usually 10 to 20 minutes to achieve pC02 of 50 to 60 mmHg) (Choice A).
2. Body temperature below 34 C (93.2 F) (Choice B).
3. EEG isoelectric for 30 minutes at maximal gain (Choice C).
4. Absence of cerebral circulation by Doppler or magnetic resonance angiography (Choice D).
5. At least 24 hours of observation in adults w ith anoxic-ischemic brain damage w ith a negative drug screen

Educational objective:
Brain death is the irreversible absence of all cerebral and brainstem reflexes. There are no spontaneous
breaths regardless of hypercarbia or hypoxemia .

Time Spent: 1 seconds Copyright USMLEW orld,LLC. l ast updated: [8/22/2014]

 1
2 Item: 4 of 14 ljl f> Mark <::J t::>
Q. ld: 5053 [ Previous Next

~ 5
6 Item 2 of 2
7
8 Using the above criteria, you are able to document that the patient is brain dead. You discuss these findings
9 w ith his family and recommend that mechanical ventilator support be w ithdrawn. Everyone in the family
10 appears to understand the situation and agrees to proceed w ith the w ithdrawal of ventilatory support.
11 One relative then w alks into the patient's room and notices some m ovements in the patient's legs. He gets
12 angry w ith you and claims that the patient is not dead. W hich of the follow ing is the m ost appropriate response

:I ~~ I
to the relative's reaction at this time?

r A. Tell the family that leg m ovements are inconsistent w ith the diagnosis of brain death [1 %]
r B. Arrange for further testing to confirm your diagnosis [4%]
r C. Obtain a neurology consultation [2%]
r D. Tell the family that the relative is probably hallucinating [1 %]
., r E. Explain calmly that limb movements can be seen normally even in a brain dead person [92%]

Explanation: User ld:

Brain death is defined as the irreversible absence of cerebral and brainstem reflexes including pupillary,
oculocephalic, oculovestibular (caloric), corneal, gag, sucking, sw allow ing, and extensor posturing. Purely
spinal reflexes, including tendon reflexes, plantar reflexes, and limb m ovements to painful stimuli can be
present in these patients. Explaining this in a calm manner should be the appropriate response to dissipate
the anger and anxiety among the family members.

(Choice A) The presence of limb m ovements is not inconsistent w ith the diagnosis of brain death .

(Choices B and C) Any further testing or consultations based on limb m ovements alone is not indicated if the
criteria for brain death have been fulfilled earlier.

Educational objective:
It is not unusual to see purely spinal reflexes manifesting as isolated limb m ovements in a brain dead person.

Time Spent: 1 seconds Copyright USMLEW orld,LLC. Last updated: [9/22/2014]

 1
2 Item: 5 of 14 ljl f> Mark <::J t::>
Q. ld: 6106 [ Previous Next
:r-1 ID1
!I=:J
6 A 78-year-old Caucasian w oman w ith a history of metastatic colon cancer, malignant ascites, and congestive
7 heart failure collapses at her son's home. She is escorted by ambulance to the hospital, w here she is
8 admitted to the intensive care unit. In the days leading up to her admission she had complained of fever,
9 productive cough, shortness of breath, and malaise. Shortly after admission she develops respiratory
10 distress that requires sedation, intubation, and ventilatory support. W ide-spectrum intravenous antibiotics are
11 begun to treat suspected pneumonia, and her diuretic dosage is increased. Responsible for her care are a
12 number of specialists, including an oncologist, pulmonologist, cardiologist, and critical care hospitalist. Each

:I ~~ I
physician meets separately w ith the patient's adult children every day to discuss his assessment and
treatment recommendations. The patient's condition moderately improves but all attempts to w ean her from
the ventilator fail. As each day passes, the family members become increasingly irritable w hen discussing
their mother's health problems, and finally accuse you of suggesting unnecessary procedures and
treatments. W hich of the follow ing is most likely responsible for the family's negative attitude?

r A. Inadequate pain management [1 %]

r B. Violation of patient's living w ill directive against intubation [1 %]
r C. Poor nursing care [1 %]
r D. Concern that health care insurance w ill not cover cost of hospital admission [6%]
., r E. Lack of communication between physicians involved in patient care [90%]

Explanation: User ld:

The issues of greatest concern for families of patients w ith cancer include pain management and the
establishment of excellent communication w ith the health professionals involved. If multiple physicians are
responsible for a patient's medical care, it is crucial that they communicate regularly about key treatment
objectives and the preferred means of accomplishing those objectives. W hen such communication is
present, all physicians involved are w ell equipped to provide family members w ith a clear and cohesive picture
of the medical team's assessment and plan . If such communication is absent, how ever, family members are
left feeling that care is being provided in a haphazard or ineffective fashion (Choice E).

Since the patient is sedated and there is no reference made to her experiencing any pain or discomfort since
her arrival at the hospital, it is unlikely that her family feels her pain management is inadequate (Choice A).
 1
2 Item: 5 of 14 ljl f> Mark <::J t::>
Q. ld: 6106 [ Previous Next
:r-1 yp > y ,mli!IJ g y g
!I=:J
6
their mother's health problems, and finally accuse you of suggesting unnecessary procedures and
treatments. W hich of the follow ing is most likely responsible for the family's negative attitude?
7
8 r A. Inadequate pain management [1 %]
9
r B. Violation of patient's living w ill directive against intubation [1 %]
10
11 r C. Poor nursing care [1 %]
12 r D. Concern that health care insurance w ill not cover cost of hospital admission [6%]

:I ~~ I ., r E. Lack of communication between physicians involved in patient care [90%]

Explanation: User ld:

The issues of greatest concern for families of patients w ith cancer include pain management and the
establishment of excellent communication w ith the health professionals involved. If multiple physicians are
responsible for a patient's medical care, it is crucial that they communicate regularly about key treatment
objectives and the preferred means of accomplishing those objectives. W hen such communication is
present, all physicians involved are w ell equipped to provide family members w ith a clear and cohesive picture
of the medical team's assessment and plan. If such communication is absent, how ever, family members are
left feeling that care is being provided in a haphaz ard or ineffective fashion (Choice E).

Since the patient is sedated and there is no reference made to her experiencing any pain or discomfort since
her arrival at the hospital, it is unlikely that her family feels her pain management is inadequate (Choice A).

No mention w as made of a living w ill, and it is unlikely that the family members w ould express concern about
intubation several days after it w as performed (Choice B).

There is no evidence that nursing care or the cost of hospital admission is of concern for the family members
(Choices C and D).

Educational Objective:
If multiple physicians are responsible for a patient's medical care, it is crucial that they communicate regularly
so that family members are provided w ith a clear and cohesive picture of the medical team's assessment and
plan .

Time Spent: 2 seconds Copyright USMLEW orld,LLC. Last updated: [9/22/2014]

 1
2 ltem:6of14 ljl f> Mark <::J t::>
:CJ Q. ld: 5417 [ Previous Next

- 5

7
8
9
10
A 78-year-old Caucasian man w ith end stage esophageal cancer is admitted to the hospital w ith severe
malnutrition and failure to thrive. The patient's caretaker tells you that he has not been able to eat or drink for
the last six w eeks. His w eight dropped from 160 pounds to 120 pounds during that time. The cancer has
spread to his lungs and liver. The patient expresses his w ishes to not receive any further treatment for the
cancer, and specifies that he does not w ant any heroic measures or interventions done to keep him alive.
11 Keeping his current clinical condition in mind, you think about offering hospice care to the patient. W hen is the
12 most appropriate time to refer this patient to hospice care?

:I ~~ I .; r A. He should be referred to hospice care now. [94%]

r B. He should be referred to hospice care two w eeks prior to his anticipated death . [2%]
r C. He should be referred to hospice care two months before his anticipated death . [2%]
r D. He should be referred to hospice care after he has cleared his hospital bills. [1 %]

Explanation: User ld:

Hospice care is usually provided to terminally ill patients w ho have a predicted life expectancy of six months or
less. The largest population of patients receiving hospice care consists of cancer patients. Other patients
receiving hospice care have terminal medical conditions such as endstage cardiom yopathy, endstage chronic
obstructive pulmonary disease, or pulmonary fibrosis.

Hospice care is based on the principle of providing compassionate and comprehensive support and care,
w hich includes, but is not limited to psychological, social, nursing, and palliative medical care to a dying
patient. It also provides support and respite care to the family members or caregivers of the terminally ill
patient. Hospice care is provided by a multidisciplinary team, w hich includes a registered nurse, nurse's aide,
social w orkers, chaplains, and a hospice physician w ho closely coordinates w ith the patient's attending
physician. It is usually provided at the patient's ow n home (home hospice care), but it can also be given as an
inpatient hospice care for patients w ho are not functionally independent.

(Choices 8 and C) There is a general tendency to delay hospice care to eligible patients by their caregivers
or attending physicians. This leads to a shorter length of stay in hospice programs, and deprives the patients
of the full benefits available to them . The patient in the above scenario has advanced esophageal cancer w ith
an expected survival of less than six months. He should be referred to hospice care program now , or as soon
as possible.
 1
2 ltem:6of14 ljl f> Mark <::J t::>
:CJ Q. ld: 5417 [ Previous Next
cancer, and specifies that he does not w ant any heroic measures or interventions done to keep him alive.

- 5

7
8
9
10
Keeping his current clinical condition in mind, you think about offering hospice care to the patient. W hen is the
most appropriate time to refer this patient to hospice care?

., r
r
A. He should be referred to hospice care now. [94%]
B. He should be referred to hospice care two w eeks prior to his anticipated death . [2%]
11 r C. He should be referred to hospice care two months before his anticipated death . [2%]
12 r D. He should be referred to hospice care after he has cleared his hospital bills. [1 %]

:I ~~ I
Explanation: User ld:

Hospice care is usually provided to terminally ill patients w ho have a predicted life expectancy of six months or
less. The largest population of patients receiving hospice care consists of cancer patients. Other patients
receiving hospice care have terminal medical conditions such as endstage cardiom yopathy, endstage chronic
obstructive pulmonary disease, or pulmonary fibrosis.

Hospice care is based on the principle of providing compassionate and comprehensive support and care,
w hich includes, but is not limited to psychological, social, nursing, and palliative medical care to a dying
patient. It also provides support and respite care to the family members or caregivers of the terminally ill
patient. Hospice care is provided by a multidisciplinary team, w hich includes a registered nurse, nurse's aide,
social w orkers, chaplains, and a hospice physician w ho closely coordinates w ith the patient's attending
physician. It is usually provided at the patient's ow n home (home hospice care), but it can also be given as an
inpatient hospice care for patients w ho are not functionally independent.

(Choices 8 and C) There is a general tendency to delay hospice care to eligible patients by their caregivers
or attending physicians. This leads to a shorter length of stay in hospice programs, and deprives the patients
of the full benefits available to them . The patient in the above scenario has advanced esophageal cancer w ith
an expected survival of less than six months. He should be referred to hospice care program now , or as soon
as possible.

Educational Objective:
Patients w ith advanced metastatic cancers or other terminal illnesses w ith an expected life expectancy of less
than six months should be evaluated for hospice care.

Time Spent: 1 seconds Copyright USMLEW orld,LLC. l ast updated: [9/2212014]

 1
2 Item: 7 of 14 ljl f> Mark <::J t::>
Q. ld: 5707 [ Previous Next
131
~
5

- 6

8
9
10
11
A 70-year-old w idow is transferred from an outlying hospital for a higher level of care to manage an acute
exacerbation of her chronic obstructive pulmonary disease. She is cared for overnight by the hospitalist, w ho
transfers care to a teaching service in the morning. The medical team responsible for the patient meets w ith
her for the first time during morning rounds, w ith the attending physician present. The new medical intern
starts the interview by calling the patient by her first name and begins to ask about her medical history. W hich
of the follow ing is the most appropriate response by the attending physician?
12

:I ~~ I r
r
A. Address the patient by first name as w ell [2%1
B. Address the patient w ith the salutation Madam follow ed by her surname [1 %1
., r C. Address the patient w ith the salutation Ms. or Mrs. followed by her surname [93%1
r D. Reprimand the intern and send the intern from the room [0%1
r E. Review outside records to determine how the patient's primary physician addresses her [3%1

Explanation: User ld:

Building a therapeutic physician-patient relationship requires finding a balance between congeniality and
formality. Congeniality allow s the patient feel comfortable about discussing personal health issues, and
formality allow s the patient to trust the physician's competence. First impressions are very important, and
initial encounters w ith a new patient should generally emphasize formality. Younger adults may be fine w ith
being called by their first name, but patients age >65 should initially be addressed as Ms., Mrs., or Mr. to show
proper respect (Choice A).

As familiarity develops between the physician and patient over time, many patients w ill prefer to be addressed
by their first name. In the absence of specific cultural or legal exceptions, patients can be addressed
according to their preference. How ever, they should be allow ed to take the lead in low ering the level of
formality, and many ethicists recommend that both the physician and patient address each other in the same
manner.

(Choice B) The salutation Madam is used in certain legal and governmental settings to address specific
individuals of high standing (eg, Madam President or Madam Ambassador). Using this form of address w ith
patients might be interpreted as inappropriate or odd.

I Choice Dl Ooenlv reorimandina the intern is unorofessional and creates an awkward situation for the oatient
 1
2 Item: 7 of 14 ljl f> Mark <::J t::>
Q. ld: 5707 [ Previous Next
131
~
5 Building a therapeutic physician-patient relationship requires finding a balance between congeniality and

- 6

8
9
10
11
formality. Congeniality allow s the patient feel comfortable about discussing personal health issues, and
formality allow s the patient to trust the physician's competence. First impressions are very important, and
initial encounters w ith a new patient should generally emphasize formality. Younger adults may be fine w ith
being called by their first name, but patients age >65 should initially be addressed as Ms., Mrs., or Mr. to show
proper respect (Choice A).

12 As familiarity develops between the physician and patient over time, many patients w ill prefer to be addressed
by their first name. In the absence of specific cultural or legal exceptions, patients can be addressed
:I ~~ I according to their preference. How ever, they should be allow ed to take the lead in low ering the level of
formality, and many ethicists recommend that both the physician and patient address each other in the same
manner.

(Choice B) The salutation Madam is used in certain legal and governmental settings to address specific
individuals of high standing (eg, Madam President or Madam Ambassador). Using this form of address w ith
patients might be interpreted as inappropriate or odd.

(Choice D) Openly reprimanding the intern is unprofessional and creates an awkward situation for the patient
and team . The attending physician should discuss minor matters of conduct w ith the intern privately.

(Choice E) Over time, patients often develop a certain level of informality w ith their primary physicians. This
may include not only verbal communication, but nonverbal interactions as w ell (eg, physical touching).
How ever, it should not be assumed that this informality w ould carry over to new , unfamiliar physicians.

Educational objective:
Adult patients (especially age >65) should generally be addressed as Ms., Mrs., or Mr., rather than by their first
names. How ever, many patients may eventually prefer a more informal style of communication after some
time in the doctor-patient relationship.

References:
1. What doctors should call their patients
2. Should general practitioners call patients by their first names?

Time Spent: 1 seconds Copyright USMLEW orld,LLC. Last updated: [9/2/2014]

 1
2 ltem:8of14 ljl f> Mark <::J t::>
:CJ5
Q. ld: 5060 [ Previous Next

6 You are managing the care of a 32-year-old football player in the intensive care unit. He w as involved in a

- 7

9
10
11
12
motor vehicle accident two days ago, and had sustained severe head injuries. The paramedics intubated him
at the scene of the accident. On the third day of hospitalization, he remains unresponsive to all stimuli and
has no spontaneous respiratory drive. He is on full ventilator support. His temperature is 36.7 C (98 F), blood
pressure is 120/70 mmHg, and pulse is 76/min. He is declared braindead by the ICU team . His family is
informed of his status, and they w ish to proceed w ith the w ithdrawal of life support. His fiance informs you
that he had always w anted to donate his organs in case of an unexpected death . W hich of the follow ing is

:I ~~ I
important to maximize the viability of donor organs?

r A. Anti-hypertensive medications to keep systolic blood pressure less than 100 mmHg [3%]
r B. Low -dose beta blockers to keep heart rate less than 60/minute [2%]
r C. Low er the ventilator rate to induce hypercapnia [4%]
r D. Maintain body temperature to less than 35 C (95 F)[39%]
., r E. Maintain normothermia w ith blankets [51 %]

Explanation: User ld:

Organ transplantation from cadaveric donors has become increasingly common in the last few years. Most of
the organs are obtained from brain dead donors. The successful recovery of viable organs for transplantation
depends on the appropriate medical care of brain dead patients; therefore, it is important to learn the basic
principles of management of these patients. The primary aim is to achieve hemodynamic stability and to
maintain physiologic homeostasis to maximize the viability of organs. A common misconception is that the
body temperature should be kept low to improve the viability of organs. In contrast, normothermia should be
maintained passively in all brain dead patients using blankets. If the body temperature is less than 35 C (95
F), active rew arming should be attempted w ith w arm air blankets and w arm intravenous fluids.

(Choices A and B) It is critical to achieve and maintain a normotensive, euvolemic state. Hypotension is very
common in brain dead patients, and may be due to the loss of sympathetic tone, systemic infections, volume
depletion secondary to losses, and diabetes insipidus. Adequate volume resuscitation is the first step in
correcting hypotension and ensuring donor viability. If systemic blood pressure still remains low , pressors
and inotropic agents may be used to improve the blood pressure.
 1
2 ltem:8of14 ljl f> Mark <::J t::>
:CJ5
Q. ld: 5060 [
liiOliiC I IOU OI YY O y ;:. YY OIIlCU lV UVIIOlC 111;:,

important to maximize the viability of donor organs?

V l ~ 011;:,
Previous Next
Ill "- O::.C V I 011 UIICAtJC"-lCU U COUI . \1\1 111"- 11 V I liiC I V II V YY III!::::t 1;:,

- 7

9
10
11
12
r
r
r
r
A. Anti-hypertensive medications to keep systolic blood pressure less than 100 mmHg [3%]
B. Low -dose beta blockers to keep heart rate less than 60/minute [2%]
C. Low er the ventilator rate to induce hypercapnia [4%]
D. Maintain body temperature to less than 35 C (95 F)[39%]
., r E. Maintain normothermia w ith blankets [51 %]

:I ~~ I
Explanation: User ld:

Organ transplantation from cadaveric donors has become increasingly common in the last few years. Most of
the organs are obtained from brain dead donors. The successful recovery of viable organs for transplantation
depends on the appropriate medical care of brain dead patients; therefore, it is important to learn the basic
principles of management of these patients. The primary aim is to achieve hemodynamic stability and to
maintain physiologic homeostasis to maximize the viability of organs. A common misconception is that the
body temperature should be kept low to improve the viability of organs. In contrast, normothermia should be
maintained passively in all brain dead patients using blankets. If the body temperature is less than 35 C (95
F), active rew arming should be attempted w ith w arm air blankets and w arm intravenous fluids.

(Choices A and B) It is critical to achieve and maintain a normotensive, euvolemic state. Hypotension is very
common in brain dead patients, and may be due to the loss of sympathetic tone, systemic infections, volume
depletion secondary to losses, and diabetes insipidus. Adequate volume resuscitation is the first step in
correcting hypotension and ensuring donor viability. If systemic blood pressure still remains low , pressors
and inotropic agents may be used to improve the blood pressure.

(Choice C) Hypercapnia has not been show n to improve organ viability, and can be even damaging to the
tissues and organs. The goal of management is to provide optimal ventilator support to prevent hypoxia and
hypercapnia .

Educational objective:
The primary goal of medical management of a brain dead organ donor is to maintain a euvolemic,
normotensive, and normothermic state.

Time Spent: 1 seconds Copyright USMLEW orld,LLC. Last updated: [9/22/2014]

 1
2 ltem:9of14 ljl f> Mark <::J t::>
:CJ 5
Q. ld: 5353 [ Previous Next

6 An 82-year-old Caucasian man is admitted to the hospital after an out-of-hospital cardiac arrest. He w as
7 successfully resuscitated and intubated in the field by paramedics, and transferred to your intensive care unit.

10
11
12
On day three of hospitalization, he remains unresponsive to all stimuli, and is deemed braindead by the
criteria . His w ife brings in the advance directives that day, w hich clearly states that the patient does not w ish
to be on any kind of life sustaining treatment, including mechanical ventilation. The w ife agrees w ith the
advance directive, and w ants to proceed w ith w ithdrawal of life support. The rest of the family, including three
sons and two daughters, gets very upset w ith the decision, and strongly oppose the w ithdrawal of life support.
1"131 They w ant to have "at least two w eeks" before the final decision regarding w ithdrawing mechanical ventilation
~ can be made. W hich of the follow ing is the m ost appropriate next step in the care of this patient?

., r A. Terminate all life sustaining support now. [72%1

r B. Terminate all life sustaining support after 2 w eeks if there is no improvement in the patient's
condition. [1 %1
r C. Talk w ith the family and discuss any secondary gains that may be affecting their decision to
w ithhold life support. [21 %1
r D. Bring up the issue w ith the ethics committee of the hospital. [5%1
r E. Move a petition in the court against the family's decision. [1 %1

Explanation: User ld:

Physicians have an obligation to relieve pain and suffering, and to prom ote the dignity and autonom y of dying
patients in their care. If the performance of these duties conflict w ith the interests of other people involved in
the patient care, the preferences of the patient should prevail. The principle of patient autonom y requires that
the physicians should respect the decision to w ithhold or w ithdraw life-sustaining treatment of a patient w ho
possesses decision-making capacity. Life-sustaining treatment is any treatment of a patient that serves to
prolong his life w ithout reversing the underlying medical condition. A competent adult patient may, via an
advance directive, formulate and provide valid consent to w ithhold or w ithdraw life-supporting treatment in the
event that any injury or illness renders that individual incompetent to make such a decision. If the patient w as
previously clear in expressing his w ishes, and is subsequently rendered incapable of making a decision, the
physician has the obligation to respect these w ishes, and inform the family/surrogate about the patient's prior
statements.
 1
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Q. ld: 5353 [

condition. [1 %]
Previous Next

r B. Terminate all life sustaining support after 2 w eeks if there is no improvement in the patient's
6
7 r C. Talk w ith the family and discuss any secondary gains that may be affecting their decision to

- 8 w ithhold life support. [21 %]

r D. Bring up the issue w ith the ethics committee of the hospital. [5%]
10
r E. Move a petition in the court against the family's decision. [1 %]
11
12
1"131 Explanation: User ld:
~
Physicians have an obligation to relieve pain and suffering, and to promote the dignity and autonom y of dying
patients in their care. If the performance of these duties conflict w ith the interests of other people involved in
the patient care, the preferences of the patient should prevail. The principle of patient autonom y requires that
the physicians should respect the decision to w ithhold or w ithdraw life-sustaining treatment of a patient w ho
possesses decision-making capacity. Life-sustaining treatment is any treatment of a patient that serves to
prolong his life w ithout reversing the underlying medical condition. A competent adult patient may, via an
advance directive, formulate and provide valid consent to w ithhold or w ithdraw life-supporting treatment in the
event that any injury or illness renders that individual incompetent to make such a decision. If the patient w as
previously clear in expressing his w ishes, and is subsequently rendered incapable of making a decision, the
physician has the obligation to respect these w ishes, and inform the family/surrogate about the patient's prior
statements.

(Choice B) The decision to w ithdraw life support should be made now , and not after two w eeks.

(Choice C) There is no evidence of any secondary gains that could affect the decision to w ithhold life
support. Furthermore, the patient has previously stated his w ishes in an advance directive. Bringing up this
issue w ould be inappropriate.

(Choices D and E) The use of courts or an ethics committee to resolve a dispute and aid in sound decision
making is necessary only in incompetent patients w ho do not have an advance directive or a surrogate
decision maker.

Educational Objective:
Patient preference should always prevail in case of any conflict regarding the w ithdrawal of life support.

Time Spent: 1 seconds Copyright USMLEW orld,LLC. l ast updated: [9/22/2014]

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2 Item: 10 of 14 ljl f> Mark <::J t::>
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6 A 46-year-old man is admitted to the hospital w ith complaints of constant mid-abdominal pain for the past five
7 days. He has a history of intravenous drug abuse, alcoholism, and chronic pancreatitis. He continues to drink
8 heavily. He has had three recent admissions for pancreatitis in the past four months. You consult a

11
12

:I ~~ I
gastroenterologist, a close friend of yours, for a possible endoscopic retrograde cholangiopancreatography.
He has also know n the patient from his previous admissions. After the procedure, he calls and tells you, "I do
not w ant to get involved in this patient's care. He is extremely non-compliant and drug-seeking, and has
slapped one of the nurses in the endoscopy lab for not giving him enough pain medications." You have been
the patient's primary care provider for the past 12 years and know that the patient can be difficult at times.
W hich of the follow ing is the most appropriate next step in the management of this patient?

r A. Ask him to w ithdraw from the patient's case if he w ishes. [5%1

r B. Tell him that he can w ithdraw from the case but he w ill not be consulted again for any of your
patients in the future. [2%1
r C. Ask him to document the patient's behavior in the chart and then w ithdraw from patient's case.
[48%1
r D. Tell him that he cannot w ithdraw from the case once he is involved in patient care. [6%1
.., r E. Tell him that he can w ithdraw from the case if some other gastroenterologist is w illing to take care
of this patient. [39%1

Explanation: User ld:

All physicians have a moral obligation to provide continuity of care for their patients. It is not appropriate to
w ithdraw or discontinue patient care in the middle of a hospitalization or during an acute ongoing medical
treatment. All physicians have the option to choose w ho they w ant to serve; how ever, once they are involved
in a case, they should not neglect the patient. If a physician w ishes to w ithdraw from a case, he can do so if
he provides the patient or the caregivers a notice long in advance so as to sufficiently permit the transfer of
medical care to another physician. In the above vignette, the gastroenterologist is already involved w ith the
patient's care since he has already performed the procedure. He can opt to w ithdraw from the patient's case
only if there is another gastroenterologist w illing to assume patient care responsibility.

(Choices A and B) Asking the physician to w ithdraw w ithout securing another gastroenterologist for the
patient is not appropriate.
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r A. Ask him to w ithdraw from the patient's case if he w ishes. [5%1

6
r B. Tell him that he can w ithdraw from the case but he w ill not be consulted again for any of your
7
patients in the future. [2%1
8

- 9 r C. Ask him to document the patient's behavior in the chart and then w ithdraw from patient's case.
[48%1
11 r D. Tell him that he cannot w ithdraw from the case once he is involved in patient care. [6%1
12
., r E. Tell him that he can w ithdraw from the case if some other gastroenterologist is w illing to take care
:I ~~ I of this patient. [39%1

Explanation: User ld:

All physicians have a moral obligation to provide continuity of care for their patients. It is not appropriate to
w ithdraw or discontinue patient care in the middle of a hospitalization or during an acute ongoing medical
treatment. All physicians have the option to choose w ho they w ant to serve; how ever, once they are involved
in a case, they should not neglect the patient. If a physician w ishes to w ithdraw from a case, he can do so if
he provides the patient or the caregivers a notice long in advance so as to sufficiently permit the transfer of
medical care to another physician. In the above vignette, the gastroenterologist is already involved w ith the
patient's care since he has already performed the procedure. He can opt to w ithdraw from the patient's case
only if there is another gastroenterologist w illing to assume patient care responsibility.

(Choices A and B) Asking the physician to w ithdraw w ithout securing another gastroenterologist for the
patient is not appropriate.

(Choice C) The patient's behavior should certainly be documented in the chart; how ever, this does not
provide sufficient grounds for w ithdrawal in the middle of the treatment.

(Choice D) As described above, the physician can w ithdraw from the case if another gastroenterologist is
w illing to assume the patient care responsibility.

Educational Objective:
Physicians can terminate the physician-patient relationship by providing a notice long in advance to sufficiently
permit the transfer of care to another healthcare provider.

Time Spent: 1 seconds Copyright USMLEW orld,LLC. l ast updated: [9/22/20141

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2 Item: 11 of 14 ljl f> Mark <::J t::>
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A 53-year-old man is admitted to the hospital after presenting to the emergency department complaining of
fever, chills, abdominal pain and sw elling, and diarrhea. Bacterial peritonitis is diagnosed, though no specific
6
etiology is yet identified. His history is significant for epilepsy, depression, eczema, and a remote
7
appendectom y. He w as diagnosed w ith epilepsy ten years ago after having three seizures in close
8
succession and has not experienced any seizures since being placed on phenytoin. He uses no other
9

-
medications at this time. He no longer drinks alcohol and has never smoked tobacco or use recreational
10
drugs. Despite continuous intravenous fluid hydration, his blood pressure begins to decline. W ithin hours of
12
admission, his blood pressure reaches 88/64 mm Hg, his pulse rises to 132/min, and he is transferred to the
intensive care unit. Blood and peritoneal fluid cultures are pending. Laboratory evaluation reveals the
:I ~~ I follow ing:

Serum chemistry
Sodium 144 mEq/L
Potassium 3.7 mEq/L
BUN 22 mg/dL
Creatinine 1.0 mg/dL

CBC
Hb 15.8 g/dL
MCV 96 fl
Platelet count 367,000/cmm
Leukocyte count 23,400/cmm

Given the circumstances, w hich antibiotic is contraindicated in the treatment of this patient?

r A. Doxycycline [21%]
r B. Gentamicin [27%]
., r C. lmipenem [34%]
r D. Tobramycin [9%]
r E. Vancom ycin [8%]

Explanation: User ld:

 1
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Q, ld: 6045 [

r A. Doxycycline [21 %]
Previous Next

6
r B. Gentamicin [27%]
7 ., r C. lmipenem [34%]
8 r D. Tobramycin [9%]
9

- 10
r E. Vancom ycin [8%]

12
Explanation: User ld:

:I ~~ I Most antibiotics are not neurotoxic, but some are associated w ith an increased risk of seizures. Conditions
that w ould predispose an individual to antibiotic-induced seizure include renal insufficiency, older age,
pre-existing CNS disease, and concomitant use of proconvulsant drugs. Of all antibiotics, beta-lactams are
the most commonly associated w ith adverse CNS events. Specifically, penicillins, cephalosporins,
monobactams, carbapenems (including imipenem), and fluoroquinolones are the antibiotics most likely to
trigger seizures (Choice C).

Doxycycline (Choice A) is a tetracycline derivative used to treat conditions such as Lyme disease or
chlamydia! infection. Concerning side effects include bone discoloration and photosensitivity. There is no
know n increased risk of seizure.

Gentamicin (Choice B) is an aminoglycoside often used in the treatment of systemic infections. Concerning
central nervous system side effects include vertigo, ataxia, and ototoxicity. There is no know n increased risk
of seizure.

Tobramycin (Choice D) is an aminoglycoside often used in the treatment of systemic infections and cystic
fibrosis. Central nervous system side effects are usually mild and can include confusion, lethargy, dizziness,
headache, and vertigo. There is no know n increased risk of seizure.

Vancom ycin (Choice E) is an antibiotic often used in the treatment of systemic infections and
methicillin-resistant Staphy lococcus aureus (MRSA) in particular. Central nervous system side effects are
usually mild and include chills and drug fever. There is no know n increased risk of seizure.

Educational Objective:
lmipenem is associated w ith an increased risk of seizure.

Time Spent: 1 seconds Copyright USMLEW orld,LLC. Last updated: [9/2212014]

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6 An 80-year-old Caucasian man is hospitalized because of ischemic stroke. He has a history of hypertension,
7 chronic renal failure, chronic obstructive pulmonary disease (COPD), and degenerative joint disease. He has
8 smoked one-and-a-half packs of cigarettes daily for 50 years. He lives at home, alone, on the third floor of a
9 five-story building. After three days in the hospital, he is ready to be discharged home, but he has been left
10 w ith severe neurologic sequelae. He cannot eat, w alk, or move w ithout assistance. His nearest relative is a
11 second-generation nephew w ho states that he has no time nor resources to take care of him. W here should

tr this patient be referred?

.; r
r
A. To a nursing home [77%1
B. To a skilled visiting nurse [8%1
r C. Home, w ith 24-hours Home Health Aid (HHA) service [9%1
r D. To a hospice [6%1

Explanation: User ld:

The patient has multiple comorbidities and needs special and close care, w hich can only be offered by a
nursing home. Even if the patient w ere declared mentally competent and refuses nursing home placement,
the Social Services Administration and Adult Protection Services can refuse to allow him to return to his home
unless there is somebody besides a home health aid (HHA) that can be responsible for his care.

(Choice B) A visiting nurse w ith adequate skills can supervise the medication and health status, but cannot
stay w ith the patient permanently.

(Choice C) The patient cannot be taken care by a HHA alone, because HHA responsibilities do not include
medication and periodical health evaluation.

(Choice D) The patient does not have a terminal condition. He is not a candidate for hospice.

Educational Objective:
Elderly patients w ho are unable to perform the basic daily living activities and take care of themselves can
return home only if they are under the care or responsibility of another person, friend, or relative, w ho w ill
guarantee adherence to the treatment and medical follow -up. If this is not possible, and if the patient has
multiple or serious medical conditions, he should be placed in a nursing home.
 1
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The following vignette applies to the next 2 items

6
7
A 72-year-old Caucasian man is brought to the emergency department (ED) due to a sudden onset of severe
8
difficulty in breathing. He has chronic obstructive pulmonary disease, and is on 2 liters of oxygen at all times.
9
10
While in the ED, he develops progressive hypoxic respiratory failure, and is intubated by the ED physician.
11
His son comes to the hospital an hour later, and gets very upset. He pulls you to one side of the room and
12
says, "Please remove the tube. He never wanted to live like this." The patient does not have any advance
directives for his health care. He regains consciousness for a few seconds while you were having a

'fr discussion with his son, but he was unable to state his wishes regarding life-sustaining treatment.

Item 1 of 2

Which of the following is the most appropriate next step in the management of this patient?

r A. Tell his son that you cannot discontinue mechanical ventilation without an advanced directive. [15%]
r B. Ask his son to consult the rest of his family first. [1 7%]
., r C. Ask him to explain the reason behind his statement in greater detail. [56%]
r D. Explain the consequences to the son and proceed with discontinuation of mechanical ventilation.
[8%]
r E. Get the hospital ethics committee involved in the case. [4%]

Explanation: User ld:

Physicians are often faced with difficult scenarios involving the withdrawal of life-sustaining treatment. The
situation may arise when a patient is rendered incompetent or is unable to participate in decision-making, and
does not have any advance directives. In such situations, the physician must still recognize and respect the
patient's autonomy and right to make healthcare decisions. It is the physician's responsibility to act in the
patient's best interest by identifying a surrogate who must make healthcare decisions for the patient based on
substituted judgment. The surrogate speaks on the patient's behalf, and must have the most knowledge on
what the patient would have done or wanted if he were able to make his own healthcare decisions. The
patient's spouse or next of kin usually acts as the surrogate decision-maker in the absence of a formally or
legally designated surrogate.
 1
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<
Previous Next
t: . (3et me nospltal etn1cs comm1ttee 1nvo1vea 1n me case. [4'7oJ

6
Explanation: User ld:
7
8 Physicians are often faced w ith difficult scenarios involving the w ithdrawal of life-sustaining treatment. The
9 situation may arise w hen a patient is rendered incompetent or is unable to participate in decision-making, and
10 does not have any advance directives. In such situations, the physician must still recognize and respect the
11
patient's autonom y and right to make healthcare decisions. It is the physician's responsibility to act in the
12 patient's best interest by identifying a surrogate w ho must make healthcare decisions for the patient based on

'fr substituted judgment. The surrogate speaks on the patient's behalf, and must have the most know ledge on
w hat the patient w ould have done or w anted if he w ere able to make his ow n healthcare decisions. The
patient's spouse or next of kin usually acts as the surrogate decision-maker in the absence of a formally or
legally designated surrogate.

The patient's son appears to have some insight into his father's w ishes w hen he claimed that "he w ould have
never w anted to live like this." The patient may have previously expressed his w ishes regarding life-sustaining
treatment to his son. The son should therefore be asked to provide more information and reasoning behind
the decision to w ithdraw mechanical ventilation at this point.

(Choice A) Telling the son that mechanical ventilation cannot be discontinued w ithout an advance directive is
incorrect. The son can assume the role of surrogate decision-maker as long as the physician believes that he
is acting in the patient's best interest.

(Choice B) The physician should discuss the situation w ith the son in greater detail before involving the family.

(Choice D) Understanding the reason and thoughts behind the son's opinion should be attempted to ascertain
if he can act as the patient's surrogate decision maker. Once a surrogate is identified, the decision
to w ithdraw or maintain ventilatory support can then be made.

(Choice E) Involvement of the hospital ethics committee is not required at this point.

Educational Objective:
Before making any decisions regarding the w ithdrawal of life support measures, it is important for a physician
to act in the patient's best interest by identifying a surrogate, w ith w hom he must effectively communicate and
discuss all issues and concerns.

Time Spent: 1 seconds Copyright USMLEWorld,LLC. l ast updated: [9/22/2014]

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2 Item: 14 of 14 ljl f> Mark <::J t::>
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6 Item 2 of 2
7
8 The patient's w hole family show s up in the hospital two hours later. He has two sons and three daughters
9 w ho appear extremely concerned by the recent events. They all live in the same tow n and are very close to
10 their parents. The patient lives alone. After prolonged discussions, the two sons agree and w ish to proceed
11 w ith the w ithdrawal of mechanical ventilation. The daughters are adamant about continuing life-sustaining
12 treatment. The daughters tell you, "Our dad never said that he didn't w ant to live". W hich of the follow ing is

~
the most appropriate next step in the management of this patient?

r A. Discontinue mechanical ventilation w hen the daughters are away. [1 %]

r B. Tell the family that you w ill continue the mechanical ventilation as you do not w ant to act against
some of the family members' w ishes. [11 %]
r C. Discontinue mechanical ventilation per the son's original request. [4%]
., r D. Involve the hospital's ethics committee in decision-making and mediation process. [83%]

Explanation: User ld:

Quite frequently, a physician is faced w ith a situation w herein multiple first-degree relatives cannot agree on
the approach to medical care, despite appropriate and adequate counseling. In such cases of conflict, the
hospital's ethics committee should be involved to act as a mediator between the different family members. In
extreme cases, the case may need to be taken to court, w here a guardian is appointed to assist in the
medical decision-making.

(Choices A, 8, and C) All the family members should be involved in the decision-making process regarding
the w ithdrawal of mechanical ventilation.

Educational Objective:
The hospital ethics committee should be involved if a conflict exists between multiple family members
regarding the appropriate approach to the patient's medical care despite adequate mediation by the physician.

Time Spent: 3 seconds Copyright USMLEW orld,LLC. l ast updated: [9/22/2014]