Question 1

A group of hospital administrators at a tertiary care center is interested in optimizing quality-related outcomes, including length of hospitalization and patient functional status for high-risk patients undergoing neurosurgical procedures.  Patients at highest risk for poor outcomes include those who are age >65 and have multiple medical comorbidities, including hypertension, diabetes, coronary artery disease, and heart failure.  The administrators are considering methods to coordinate care between the attending surgeon and a hospitalist-led, multidisciplinary team.  Hospital administrators decide to implement a team-based care model that involves comanagement of surgical patients by surgeons and a hospitalist-led, multidisciplinary team that includes physical therapists, a social worker, pharmacists, and a nurse case manager.  A series of team meetings is held to define team goals, member roles, and methods for tracking desired quality and outcomes data.  Which of the following approaches is recommended to improve team performance and clinical quality?

Accepted Answer

Explanation: Comanagement is a model in which a surgeon and a generalist physician-led multidisciplinary team share responsibility for patient care and is associated with improvement in quality indicators and certain health outcomes for high-risk patients. Because comanagement involves multiple team members and disciplines, the following best practices are recommended to optimize the effectiveness of this model: Define clear, specific roles for each team member. Unnecessary overlap of tasks among team members may lead to errors due to duplicated efforts (eg, multiple team members administering insulin in response to a patient's elevated glucose) (Choice B). Refine clinical processes through systematic review and continuous cycles of testing and assessment. Compared to a single comprehensive analysis, an ongoing, iterative approach is more effective in improving quality outcomes (Choice C). Track important clinical outcomes (eg, mortality, readmission rates) to assess overall effectiveness of the care model. (Choice A) Six sigma is a quality improvement approach that seeks to eliminate serious defects to a statistical standard (eg, error rate <99.997%). This method is appropriate to reduce catastrophic outcomes (eg, wrong-site surgery) but is less effective in addressing and improving the complex and multifaceted goals in a comanagement system. Educational objective: Comanagement is a care model in which a surgeon and a comanaging generalist physician (ie, hospitalist) share responsibility for patient care. An ideal comanagement model defines clear, specific roles for each team member, continuously refines clinical processes through quality improvement, and tracks important clinical outcomes. References: Evaluation of internal medicine physician or multidisciplinary team comanagement of surgical patients and clinical outcomes. (http://www.ncbi.nlm.nih.gov/pubmed/2765514) Surgical comanagement by hospitalists: continued improvement over 5 years. (http://www.ncbi.nlm.nih.gov/pubmed/217186)

Question 2

A 59-year-old obese woman with a history of type 2 diabetes mellitus and chronic obstructive pulmonary disease (COPD) is admitted with COPD exacerbation.  Management is complicated by difficulty controlling the patient's blood glucose, with levels of 100-300 mg/dL throughout the day.  On her second hospital day, a 7 x 3 cm abscess of her left buttock is found and requires incision and drainage.  Following the procedure, the surgeon instructs the overnight hospitalist to obtain serial ultrasound examinations to monitor the abscess.  During the course of signing out, the hospitalist expresses concern about the patient's fluctuating blood sugars, provides details on the status of her COPD, and mentions the drainage of the abscess but forgets to mention the need for follow-up ultrasound examination.  Due to this oversight, the abscess is not reexamined for several days and worsens significantly, requiring more extensive surgical intervention.  Following a review of the adverse outcome, the hospital administration forms a committee to improve patient handoffs between medical staff members.  Which of the following interventions would most significantly improve the quality of patient handoffs?

Accepted Answer

Explanation: Ineffective patient handoffs can cause significant delays in care, workflow redundancies, and adverse patient outcomes due to errors or oversight. Handoffs frequently occur in less-than-ideal environments, with time constraints and interruptions from staff members. However, most errors result from a failure to communicate in a systematic manner that incorporates the "big picture" and assists with anticipatory decision-making. Using an organized template or a checklist has been shown to improve sign-out efficacy and accuracy. Sign-outs should be conducted verbally, face-to-face, with an updated, succinct written component. Essential components of an effective sign-out are shown in the table. 11ec2b69_c0d7_a08c_8f63_b5ea3f08994b_MD0005_00 (Choice A) A quiet workplace in which physicians can communicate patient information is ideal but has not been shown to improve outcomes as effectively as systematic checklists and templates. (Choice B) Extensive and detailed notes on each patient can be challenging for a new physician, who often requires direct and concise data to act quickly in time-sensitive situations. When information is unorganized and non-systematic, it is frequently overlooked or misinterpreted. (Choice C) Although it is important for physicians to designate an appropriate amount of time for patient sign-outs, additional time does not necessarily lead to improved quality of sign-outs or better outcomes. (Choice D) Although a bedside sign-out can help acquaint the new physician with the patients and may allow for a better focus on patient care, it has not been shown consistently to improve the quality of handoffs and requires greater amounts of limited physician time. Educational objective: Undesired medical outcomes (eg, errors, inefficiencies, delays) often result from inadequate patient handoffs between medical providers. Use of sign-out procedures that incorporate systematic checklists and templates can reduce the incidence of poor outcomes. References: Development and implementation of an oral sign-out skills curriculum. (http://www.ncbi.nlm.nih.gov/pubmed/17674110) Implementation of an emergency department sign-out checklist improves transfer of information at shift change. (http://www.ncbi.nlm.nih.gov/pubmed/25130675)

Question 3

A 74-year-old man is brought to the emergency department after being found unconscious at home.  Emergency medical personnel report that he was in complete heart block when they arrived.  The patient's history is significant for a myocardial infarction 12 years ago, with subsequent congestive heart failure.  He has been admitted to the hospital twice over the past 3 months, once for decompensated heart failure and once for atrial fibrillation with rapid ventricular response.  In reviewing the home medications brought in by his wife, the physician notes that the patient is taking aspirin; dabigatran; furosemide; apixaban; lisinopril; extended-release metoprolol; and atenolol.  The wife reports that he takes these medications regularly and they were all prescribed by his doctors.  He sees a primary care physician and a cardiologist, who work within the same hospital system.  The patient's son, a pharmacist, expresses disappointment  after learning of his father's complete heart block and prescription for 2 different beta blockers and oral anticoagulants.  Which of the following actions would be most helpful in preventing the medical error that led to this patient's outcome from occurring again in the future?

Accepted Answer

Explanation: 11ec2b69_c0d7_044b_8f63_cb753de65135_MD0005_00 Preventable medical errors present considerable risk to patient safety. Within large systems of care, checks and balances exist to prevent or minimize medical errors and resulting adverse events. This system of safety checks may fail, requiring an examination of what occurred and how it could have been prevented. A root cause analysis is a quality improvement tool used to identify what, how, and why an undesirable outcome occurred. When investigators determine why an event or failure occurred, they can recommend corrective measures to prevent future occurrences. Root cause analysis requires 5 steps (Table). The first involves collecting data about the event. Data collection often includes interviewing multiple individuals involved to understand how and why the adverse outcome occurred. Review of the medical record and speaking with the patient's pharmacist, cardiologist, and wife would assist in understanding the causal factors leading to the adverse outcome, but analyzing each component individually may not be sufficient in understanding the underlying causes of the error. Root cause analysis would include these components in addition to systematic analysis of contributing factors (Choices A, B, C, and D). The second step involves creating a flow chart with causal factors, or contributors that, if eliminated, could have prevented the outcome or reduced its severity (ie, human error). The third step involves identifying the reasons behind each causal factor, termed the root cause. This step assists investigators in understanding why particular causal factors exist or occurred. For example, the primary care physician may not have realized that the patient was already on a beta blocker/anticoagulant (causal factor), due to inadequate training on how to use a new electronic health record system, due to lack of funding for adequate training (root cause). The fourth step involves generating recommendations and implementing them. The fifth step requires assessing the success of implemented changes. Educational objective: Root cause analysis is a quality improvement measure that aims to identify steps leading to a preventable adverse outcome within a system of care. It involves data collection through chart review and interviews of multiple individuals involved. References: A cross-sectional study on the relationship between utilization of root cause analysis and patient safety at 139 Department of Veterans Affairs medical centers. (http://www.ncbi.nlm.nih.gov/pubmed/23367650) Applying root cause analysis to promote the medication safety of continuous drug infusions for infants. (http://www.ncbi.nlm.nih.gov/pubmed/24677005) The nature and causes of unintended events reported at ten emergency departments. (http://www.ncbi.nlm.nih.gov/pubmed/19765275)

Question 4

A 35-year-old woman comes to the office for the third time in a month for follow-up.  She called the office the night before reporting that her chest felt "tight" and was advised by the on-call physician to make an urgent office appointment today if she felt the need to be seen.  The patient arrives an hour before her scheduled appointment and enjoys chatting with the office staff.  She has a history of irritable bowel syndrome, dermatitis, anxiety, and mild asthma.  Her record indicates that she has also called the office multiple times after hours to discuss various nonurgent matters, including questions about diet and hypoallergenic products.  Today she is breathing normally and shows the physician a chart she has made documenting her asthma episodes and triggers.  Temperature is 36.7 C (98 F), blood pressure is 120/80 mm Hg, pulse is 72/min, and respirations are 14/min.  Examination shows no abnormalities.  The patient says, "I didn't have time to show you this chart at our last appointment; the on-call doctor advised me to come in and show it to you."  Which of the following is the best response to the patient's behavior?

Accepted Answer

Explanation: This patient's frequent appointments and after-hours phone calls for nonurgent matters indicate a dependent behavior pattern. These patients are needy, and managing their demands for attention and reassurance can be challenging. The best approach is to be empathic and nonjudgmental but establish clear boundaries. The physician should explain what situations warrant an urgent call and direct the patient to other resources for guidance on routine questions. Making sure that all members of a treatment team are in agreement on maintaining clear boundaries with the patient can also be helpful. This can prevent staff burnout and minimize the potential for avoiding, or expressing anger toward, the patient. Excessively dependent patients may have underlying psychiatric problems (eg, anxiety, trauma-related and personality disorders) that require evaluation and treatment. However, this patient has not expressed psychological symptoms, and it would be premature to suggest a psychiatric evaluation (Choice C). Suggesting longer appointments is likely to be an impractical and temporary solution (Choice D); most dependent patients will still be needy regardless of appointment length. (Choice A) This statement may be perceived as dismissive and avoids the main issue, which is one of multiple phone calls and visits. If a limit regarding phone calls is not set, the pattern is likely to continue. (Choice E) This statement sets a limit but leaves it to the patient to interpret what is meant by a "true emergency." It would be more productive for the physician to explain what conditions and situations warrant immediate attention. Educational objective: Excessively needy patients who demand attention for nonurgent concerns are best managed by setting limits in a firm but empathic manner. Educating patients about specific guidelines for contacting the physician outside of office hours and providing alternate resources for routine questions are helpful strategies. References: Managing difficult encounters: understanding physician, patient, and situational factors. (http://www.ncbi.nlm.nih.gov/pubmed/23547575)

Question 5

A 3-day-old boy is brought to the office by his mother for a weight check.  The patient was born via spontaneous vaginal delivery to a 26-year-old primigravida following an uncomplicated pregnancy.  Apgar scores were 9 and 9 at 1 and 5 minutes, respectively.  The patient is breastfed exclusively every 3-4 hours and sleeps approximately 15 hours a day.  On physical examination, he is alert and quiet in his mother's lap.  The examination is unremarkable.  Anticipatory guidance is given regarding the patient's expected feeding and elimination habits, as well as upcoming developmental milestones.  The topic of vaccinations is raised, and the mother adamantly states that she is unwilling to have her child vaccinated.  She says, "I know you might disagree with me, but I feel that vaccines can make my son autistic.  I refuse to let him be exposed to them."  A prolonged discussion regarding vaccine risks and benefits does not change her beliefs.  She is given additional written information regarding immunization facts.  Which of the following is the best next step in management of this family?

Accepted Answer

Explanation: 11ec2b69_c0d3_5ac7_8f63_f582780f8bf6_MD0005_00 Vaccine hesitancy is defined as delay or refusal of immunization. Most families with vaccine hesitancy have safety concerns, some of which are known adverse events (eg, site reactions). However, many concerns are the result of misinformation. Common misconceptions and clarifications include: "Vaccines cause autism": Following the retraction of the fraudulent Wakefield study, many large-scale, systematic reviews have consistently shown no association between immunization and autism spectrum disorder. "Vaccines overload the immune system": Exposure to multiple antigens at once has not been shown to be harmful, and immunization has no impact on subsequent immune responses to other antigens. "Natural infection is better": Natural infection is associated with higher risk for complications compared to immunization. For example, the risk for hospitalization for severe dehydration from rotavirus infection is much greater than the rare chance of intussusception after the vaccination. The first step in approaching vaccine-hesitant parents is engaging in open dialogue. This should include acknowledging parental concerns, correcting misinformation, and reviewing evidence-based risks and benefits of immunization, as was done with this family. Although some vaccine-hesitant families ultimately refuse vaccination, up to 50% can be convinced, over time and using continued education and nonjudgmental, honest discussions, to immunize. Lack of vaccine acceptance at an initial visit should not deter providers from attempting to establish trust and initiating discussion at subsequent encounters (Choice D). (Choice A) Passive immunoprophylaxis (ie, injected immunoglobulin) can be considered for unimmunized individuals after certain high-risk, infectious exposures (eg, varicella) but is not a substitute for routine immunization. (Choice C) Alternate vaccine schedules are associated with delayed or incomplete immunizations. Although they can be considered for families who refuse to vaccinate despite multiple conversations, this child is only age 3 days, so continued dialogue may convince the family to vaccinate on the standard, evidence-based schedule. This option would be reasonable if the family's beliefs are unchanged after subsequent encounters. (Choice E) Parents may request a joint discussion to better understand vaccine risks and benefits. However, this mother, the decision-maker at this encounter, is adamant in her beliefs. Suggesting that both parents come for future visits would likely break trust between the provider and the mother. Educational objective: The best approach to vaccine hesitancy or refusal is an open, honest conversation that includes listening to parental concerns, correcting misinformation, and discussing the risks and benefits of immunization. Initial vaccine refusal should be followed with ongoing dialogue at subsequent visits. References: Countering vaccine hesitancy. (http://www.ncbi.nlm.nih.gov/pubmed/27573088) Identifying and addressing vaccine hesitancy. (http://www.ncbi.nlm.nih.gov/pubmed/25875982)

Question 6

A group of hospital administrators at a tertiary care center is interested in optimizing quality-related outcomes, including length of hospitalization and patient functional status for high-risk patients undergoing neurosurgical procedures.  Patients at highest risk for poor outcomes include those who are age >65 and have multiple medical comorbidities, including hypertension, diabetes, coronary artery disease, and heart failure.  The administrators are considering methods to coordinate care between the attending surgeon and a hospitalist-led, multidisciplinary team.  Which of the following team-based approaches is associated with improved quality of care?

Accepted Answer

Explanation: Many adults undergoing inpatient surgery have serious medical comorbidities (eg, coronary artery disease) or risk factors (eg, advanced age) that increase the risk of suboptimal outcomes (eg, extended length of stay). Multispecialty, team-based approaches can facilitate improved outcomes by applying collective expertise to optimize management. Comanagement is a team-based model in which the primary surgeon and a comanaging generalist physician (ie, hospitalist) share responsibility for a patient's care. Comanagement is characterized by the following features: Automatic involvement of the comanaging physician for patients who meet specific criteria (eg, age, high-risk diagnosis). This contrasts with traditional models in which the hospitalist is involved only if the surgeon initiates a consult (Choices C and D). Broad scope of practice for the comanaging physician, who proactively identifies medical conditions that need to be addressed and manages them (eg, writing orders, calling additional consultants as needed). This contrasts with traditional models, in which the hospitalist addresses only concerns identified by the primary surgeon (Choice A). Physician roles and responsibilities are often formally delineated in a written agreement, in contrast to traditional, informal consultation models. Current evidence suggests that comanagement improves specific patient outcomes (eg, length of stay, functional recovery) and quality of care, especially when the comanaging physician operates as part of a multidisciplinary team (eg, including nursing, pharmacy, social work). Educational objective: Comanagement is a team-based model in which a surgeon and a generalist physician (ie, hospitalist) share responsibility for a surgical patient's care. In contrast to traditional consultation models, the hospitalist is often automatically involved in the patient's care and proactively identifies and manages the patient's medical conditions. References: Evaluation of internal medicine physician or multidisciplinary team comanagement of surgical patients and clinical outcomes. (http://www.ncbi.nlm.nih.gov/pubmed/32369179) Surgical comanagement by hospitalists: continued improvement over 5 years. (http://www.ncbi.nlm.nih.gov/pubmed/32118566)

Question 7

A 65-year-old man is brought to the emergency department by his neighbor after fainting in his garden.  The neighbor says, "We were discussing how to manage weed overgrowth this season, and suddenly he started slurring his words, began drooling, and fell to the ground."  The patient cannot remember what happened, reports that he feels fine, and says, "It was probably just the heat."  Medical history is significant for hypercholesterolemia, hypertension, gout, and major depressive disorder.  Medications include simvastatin, lisinopril-hydrochlorothiazide, escitalopram, and allopurinol.  The patient lives with his daughter, who is his next of kin. The patient is mildly depressed and nonsuicidal.  Blood pressure is 124/72 mm Hg and heart rate is 78/min.  Neurological examination shows no localizing signs, and the remainder of the examination is normal.  The physician leaves to order a full blood panel and ECG.  On return to the patient's room, the physician finds him standing next to his bed, fully dressed and ready to leave.  The patient says, "I know you want to do tests but I am really fine and just want to get home."  The physician explains that cardiovascular events such as a heart attack or stroke need to be ruled out.  The patient still refuses and says, "I understand your concerns and the risks involved, but I really think it was just the heat.  I will feel better at home."  Which of the following is the most appropriate next step in management of this patient?

Accepted Answer

Explanation: 11ec2b69_c0d4_6c39_8f63_59294cfb93ed_MD0005_00 Every effort should be made to prevent patients with high-risk medical conditions from refusing intervention. This includes fully explaining the patient's medical condition, proposed tests or treatments, and the disease-specific risks of refusing interventions and leaving the hospital, including the risk of death. The physician should ask the patient to explain the reason for refusing treatment and address any modifiable external influences (eg, financial concerns, social or work responsibilities). If the patient continues to insist on discharge, the physician must assess the patient's decision-making capacity to refuse care. Decision-making capacity requires that the patient demonstrate an understanding of the proposed treatment, can state the risks and benefits of refusing treatment, and can communicate a clear and consistent decision. Patients determined to have decision-making capacity should be discharged against medical advice. This patient appears to have decision-making capacity. He understands his medical condition and the risks of refusing treatment, and communicates a clear and consistent decision. The physician should discharge him against medical advice with instructions to seek follow-up care, including returning to the emergency department if necessary, and carefully document the discussion. (Choice A) This patient has decision-making capacity; there is no need for a surrogate decision maker. (Choice C) Although having the neighbor accompany the patient would increase his safety, the decision to discharge is not dependent on this but rather on respecting the autonomy of a patient with intact decision-making capacity. (Choice D) Any treating physician can assess capacity; assessment does not have to be done by a psychiatrist. If there is an indication that unstable psychiatric conditions (eg, severe psychosis, depression with suicidality) are impairing a patient's decision-making capacity, a psychiatric consultation should be requested to guide further management. (Choice E) If a patient has a life-threatening condition and a physician determines that the patient does not have the capacity to refuse treatment, the patient can be held while further consultation and management take place. These include contacting the next of kin and treating any reversible conditions that could be impairing capacity (eg, delirium, psychosis, severe depression). Educational objective: Patients with decision-making capacity have the right to refuse testing or treatment. In these cases, discharge against medical advice should be documented and instructions for adequate follow-up care provided. References: The importance of a proper against-medical-advice (AMA) discharge: how signing out AMA may create significant liability protection for providers. (http://www.ncbi.nlm.nih.gov/pubmed/21715123) Discharge against medical advice: ethical considerations and professional obligations. (http://www.ncbi.nlm.nih.gov/pubmed/18951403) Discharge against medical advice in the United States, 2002-2011. (http://www.ncbi.nlm.nih.gov/pubmed/28291588)

Question 8

A 9-year-old boy is brought to the emergency department by his aunt with right arm pain and swelling after falling in his backyard.  The aunt says that the boy fell off the monkey bars and landed on his right hand.  There was no head injury or vomiting.  On physical examination, the child screams in pain and feels tingling in his right fifth digit.  The right elbow is swollen and deformed.  The right radial pulse is 1+ and sensation is intact.  Radiographs are obtained.  The boy's aunt is not his legal guardian but would like him to be treated for this injury.  His parents are currently out of town and cannot be reached by phone.  The aunt mentions that the boy was treated at this hospital 3 months ago and his mother gave consent for treatment at that time.  Which of the following is the most appropriate next step in the management of this patient?

Accepted Answer

Explanation: 11ec2b69_c0d3_f708_8f63_416d5de3c3ca_MD0005_00 Consent for treatment of minors should be obtained from either a parent or legal guardian; exceptions include specific medical circumstances or emancipated minors (Table). The criteria for medical emancipation vary by state but generally apply to minors with children, those who have served in the military, those who are or have been married, and those living away from home without parental financial support. Although this child does not meet criteria for emancipation, he should be treated regardless of parental consent as he is presenting with a medical emergency and delaying treatment could harm his health. The patient has a type III supracondylar fracture with possible neurovascular compromise based on the presence of a diminished radial pulse and paresthesias. Delaying treatment due to lack of parental consent (Choice A) is inappropriate as the pain is severe and there is high risk of injury-related complications. The parents should be notified as soon as possible after timely treatment is provided. type III supracondylar fracture neurovascular compromise (Choice B) Fractures that are highly suggestive of non-accidental trauma include rib fractures, metaphyseal corner fractures, and multiple fractures in various stages of healing. This patient's supracondylar fracture is consistent with the reported mechanism; child abuse is unlikely. In addition, parents are generally not allowed to refuse medical investigation when child abuse is suspected. (Choice D) The aunt cannot consent to treatment unless she is the boy's legal guardian. (Choice E) Although extended consent can be obtained in certain circumstances (eg, blood transfusions in oncology patients), consent for treatment is generally obtained for each new medical encounter and procedure. Previous parental consent does not guarantee consent during a new encounter. Educational objective: Consent for treatment is generally obtained from a parent or legal guardian prior to initiating medical treatment for a minor except in specific circumstances. These circumstances include emergency care, sexually transmitted infections, and emancipated minors. References: Consent for emergency medical services for children and adolescents. (http://www.ncbi.nlm.nih.gov/pubmed/12612264)

Question 9

A 79-year-old woman is brought to the office by her daughter for a follow-up visit after a fall.  Two days ago, her knees gave out while standing up from bed, and she fell to the floor.  There was no loss of consciousness, and evaluation in the emergency department revealed no significant trauma.  The patient has a history of frequent falls and has been prescribed a walker but does not use it consistently.  Other chronic medical problems include hypertension, type 2 diabetes mellitus, osteoarthritis, and obesity.  The patient uses oxygen therapy for idiopathic pulmonary fibrosis.  She lives with her daughter and performs basic activities of daily living independently.  The patient no longer drives; her daughter shops for food for her and takes her to family events and church services.  Her daughter says, "I am working 2 jobs and am finding less time to care for my mother.  I worry that she may fall again and break her hip.  I have also found that sometimes she forgets to take her medications."  Blood pressure is 156/80 mm Hg and pulse is 72/min.  Gait is unsteady but no focal weakness or sensory loss is present.  The patient's daughter would like to learn more about home health services for her mother.  Which of the following conditions qualifies this patient for home health services?

Accepted Answer

Explanation: Home health services allow infirmed patients to receive skilled care at home. To qualify, individuals must have a serious illness or injury that makes leaving the home exceedingly difficult or taxing. Patients must also meet the criteria for being "homebound," which includes >1 of the following: Use of a supportive device (eg, crutch, cane, wheelchair, walker) for mobility Ability to leave home only with the assistance of another individual Medical contraindication to leaving home This patient meets the criteria for being homebound based on the use of a walker and her inability to leave home without her daughter's assistance. She would likely benefit from skilled care such as physical and occupational therapy and medication adherence assistance. (Choice A) Having a terminal disease with <6 months of life expectancy would qualify a patient for hospice services; terminal illness is not a requirement for home health services. This patient has no clear evidence of illness that is likely to result in death in a short time. (Choice B) This patient is homebound but able to perform basic activities of daily living. As such, she does not currently need nonskilled care (eg, bathing, grooming, dressing). This patient requires skilled care. (Choice D) Lacking support and having an overburdened caregiver are qualifications for a caregiver relief program, not home health services. Caregiver relief programs aid caregivers in the care of chronically ill patients. (Choice E) Patients who are not homebound can receive skilled care in the ambulatory setting and do not generally require (or qualify for) home health services. Educational objective: Patients are considered homebound if they use a supportive device (eg, walker, wheelchair) for mobility, are unable to leave home without another person's assistance, or cannot leave home due to a medical contraindication. Homebound patients generally qualify for home health services if leaving the home is exceedingly taxing or difficult. Common skilled home health services include physical and occupational therapy, medication compliance monitoring, and wound care.

Question 10

A 75-year-old woman is admitted to the intensive care unit due to worsening shortness of breath.  Medical history is significant for systolic heart failure with a left ventricular ejection fraction of 10% on recent echocardiogram.  Evaluation reveals acute hypoxic respiratory failure due to cardiogenic pulmonary edema.  The patient also has a history of three-vessel coronary artery disease, diabetes mellitus, and chronic kidney disease.  Her heart disease is not amenable to any intervention or surgery due to her poor functional status, and she has been treated with maximal medical therapy as tolerated.  She was hospitalized a month ago due to an exacerbation of congestive heart failure and was discharged to a nursing facility after responding to treatment.  The patient has limited mobility and requires assistance for activities of daily living.  In the intensive care unit, her symptoms slowly improve with noninvasive positive-pressure ventilation, ionotropic therapy, and intravenous diuretic treatment, but her kidney function gradually deteriorates.  The critical care physician and nephrologist recommend that all treatments be stopped and that the patient receive comfort care only.  The patient's son agrees and says, "The time has come to let go."  The patient, however, wants "everything to be done" and even to receive cardiorespiratory resuscitation if required.  Which of the following is the most appropriate course of action?

Accepted Answer

Explanation: Issues regarding withdrawal of care can become complex, especially when there is disagreement among physicians and patients about the appropriate treatment course. This patient has an extremely poor prognosis and what many would consider a poor quality of life. However, poor prognosis is not the same as medical futility, which has been defined as treatment that can have no beneficial physiologic effect. This patient has recently responded to aggressive treatment that resulted in prolonging her life. She is alert and possesses adequate decision-making capacity. Although the physician may not agree that this is the best course, her wishes to continue aggressive treatment should be honored based on the ethical principle of autonomy. Physicians are not ethically obligated to provide treatment that is futile (eg, dialysis in an unconscious patient expected to die from end-stage cancer in a few days). A high degree of certainty is required for the application of the concept of medical futility. This can be difficult to ascertain in cases of end-stage kidney disease or heart failure, such as in this patient, as there is a chance that these conditions may improve with treatment, albeit only minimally or briefly. The issues of cost-effectiveness and allocation of resources should not be considered in the determination of futility. (Choice A) The patient is awake and alert and has the capacity to make her own end-of-life decisions. It would be inappropriate to ask the son to make decisions for her. (Choice C) Although prognosis is poor, aggressive treatment and intensive monitoring have resulted in temporary improvement, and it cannot be determined with a high degree of certainty that further treatment is medically futile. It would be inappropriate to treat the patient with comfort-care measures only when she has specifically stated that she wants all treatments to be performed. (Choice D) This patient still has adequate decision-making capacity and is making a rational decision. She has firmly stated her wishes to continue all treatments; she does not wish to begin hospice care. (Choice E) It would be inappropriate to transfer the patient to another hospital. The patient's wishes should be upheld by the current treatment team. Educational objective: Patients have a right to make their own end-of-life decisions even if the treating physician does not agree. With the exception of requests for treatments that are clearly medically futile, a patient's autonomy in end-of-life decisions must be upheld. References: Challenges in end-of-life decisions in the intensive care unit: an ethical perspective. (http://www.ncbi.nlm.nih.gov/pubmed/23299401) Perspective: medical futility: a contemporary review. (http://www.ncbi.nlm.nih.gov/pubmed/28001142)

Question 11

A 70-year-old woman is brought to the office by a friend who became concerned at finding her very weak and pale during a recent visit.  The friend had not seen the patient in more than 6 months and was shocked at her condition.  The patient says, "I feel very tired and have to sit down a lot to rest."  She has had these symptoms for the past 10 months, but they are becoming progressively worse.  She was diagnosed with primary myelofibrosis 2 years ago.  The patient was not offered bone marrow transplantation due to her age; instead, she has received blood transfusions on more than 10 occasions, as well as erythropoietin and androgens, which have yielded poor results.  She has no other medical problems and takes no other medication.  The patient is widowed and lives with her son, who cares for her.  Temperature is 36.7 C (98 F), blood pressure is 120/70 mm Hg, pulse is 110/min, and respirations are 20/min.  She appears pale and undernourished, with significant muscular wasting.  Auscultation reveals tachycardia.  Hepatosplenomegaly is present.  Laboratory results are as follows:  Three months ago, when her hemoglobin level was 8.0 g/dL and her hematocrit was 24%, the patient stated that she did not want any more blood transfusions or treatment.  She understands that her condition is worsening but has not changed her mind, and continues to refuse any type of therapy.  Which of the following is the most appropriate course of action?

Accepted Answer

Explanation: The only effective medical treatment for primary myelofibrosis is allogenic hematopoietic cell transplantation. Unfortunately, only patients age <60 can be considered as candidates. The rest are treated with palliative measures only. This patient has a number of factors associated with poor prognosis: significant weight loss; hemoglobin level <10 g/dL, leukopenia (white blood cells <4,000 /mm³) and platelet count <150,000/mm³. The principle of autonomy includes a patient's right to refuse treatment. Although it may be difficult for the physician to forgo treatment that could improve this patient's symptoms, her decision must be respected. She should be allowed to go home with arrangements for palliative care if she chooses. Unless the court rules that this terminally ill patient is incompetent, she can continue to exercise her right to determine what she thinks is best. (Choices B and C) This patient has clearly stated her decision and has not requested assistance from her friend or son. Involving them is not indicated and may make the patient feel undermined. (Choice D) Patients should be referred to a psychiatrist if there is concern that an underlying psychiatric illness (eg, psychosis, depression) is impairing the patient's decision-making capacity and/or requires treatment. This patient shows no evidence of psychiatric illness or lack of decision-making capacity. (Choice E) This patient has refused any type of therapy for her condition. Sending her to the emergency department against her wishes violates her autonomy. Educational objective: Patients with untreatable diseases and a poor quality of life, and who have already tried different therapies, may sometimes refuse to accept any kind of treatment. The principle of autonomy includes a patient's right to refuse treatment, and the physician must respect the patient's decision.

Question 12

A 46-year-old truck driver comes to the office due to fatigue.  He has consumed energy drinks during the past 3 months to complete his driving routes.  He sleeps most of the day on weekends and avoids his wife and kids.  The patient says, "I even slept through my son's baseball game.  I felt really bad about that."  He has a history of chronic back and knee pain due to a motorcycle accident.  The patient's medications include naproxen.  He drinks a few beers with friends but has not socialized much lately.  The patient's wife says that he is never there for her and they fight constantly.  He has no history of manic symptoms or other psychiatric history.  Physical examination and routine laboratory studies are unremarkable.  Mental status examination shows depressed mood and sad affect.  The patient says he has had thoughts of suicide but would never do anything because of his children.  He is diagnosed with depression and started on sertraline.  He returns for a 3-week follow-up, reporting little change.  The patient says, "Some days I think I'm feeling a little better, but other days are really bad.  I don't know about these pills.  I've been taking them and don't have any side effects, but I still feel pretty bad."The patient returns for another follow-up 4 weeks later.  He says, "At first, I really thought the medication was working and things were finally turning around for me.  For a couple of weeks I felt less depressed, almost normal.  I had more energy and was doing more activities with my kids and arguing less with my wife.  Then I went on a long truck route halfway across the country, and things just started falling apart.  Now, I'm not only depressed again, but I feel shaky and hyper at the same time.  I needed to stay awake to drive for 16 hours straight, and then afterward I still couldn't fall asleep.  My back has been hurting badly, too, and I had to take something stronger for the pain.  One night, I even thought that my wife might be having an affair, but I know that's crazy!"  On mental status examination, the patient is alert, anxious, and mildly tremulous.  He has no suicidal thoughts.  He is concerned that the sertraline has stopped working. 
Which of the following is the most likely explanation for the patient's symptoms?

Accepted Answer

Explanation: This patient has been on sertraline for a total of 7 weeks and showed significant signs of improvement prior to a road trip (ie, better mood, increased energy, improved interactions with his wife and children). When a patient appears to lose antidepressant response, a careful interim history that includes new psychosocial stresses, medical problems, and substances used should be obtained. Most likely, this patient's recent deterioration is due to increased substance use during his road trip. Although his alcohol use was not quantified previously, he is known to drink "a few" beers. He also uses energy drinks, is possibly using other stimulants to help him stay awake, and shows signs and symptoms of sympathetic activation (feeling "shaky" and "hyper," tremulousness on examination). He is also using pain medication other than naproxen. Alcohol, opiate, and other illicit substance use may be exacerbating his depression. Insomnia, hyperactivity, and paranoid ideation may be precipitated by amphetamines or other stimulants. A detailed substance use history will help to determine what substances may be contributing to his worsening depression and inadequate response to the antidepressant. (Choice A) The patient previously stated that he had no side effects on sertraline. Activating side effects (eg, insomnia, anxiety), if they occur, typically develop shortly after initiation of the antidepressant. (Choice B) Although antidepressant-induced mania should be considered, the time course of symptoms in relation to his trip and lack of history of manic symptoms at his age suggest that substance use is more likely. (Choice C) Although depressive relapse is a possibility, the patient's abrupt deterioration and signs of sympathetic activation (rather than return of fatigue that had characterized his depression) are more suggestive of a substance-related cause. (Choice D) This patient has no history of psychosis and has insight into his paranoid thoughts, suggesting that his symptoms are substance-induced. Educational objective: Depressed patients who deteriorate after initial signs of improvement on an antidepressant should be assessed carefully for substance use. Alcohol, stimulants, and opiates can exacerbate depressive symptoms and contribute to poor antidepressant response. References: Assessment and treatment of mood disorders in the context of substance abuse. (http://www.ncbi.nlm.nih.gov/pubmed/26246792)

Question 13

A 46-year-old woman with a history of hypertension and type 2 diabetes mellitus is traveling out of state for work.  While out jogging, she slips and falls and fractures her ankle.  The patient belongs to an employer-sponsored private health insurance plan which has an annual deductible of $3,000.  Prior to this incident, she had paid $3,000 this year to other health care providers for covered health care expenses.  The patient visits an in-network urgent care provider, where she receives an x-ray, an injection of pain medication, and a cast on her injured ankle.  Three months later, the patient receives a bill from the urgent care facility stating that she owes $1,000 for services rendered.  Which of the following is most accurate?

Accepted Answer

Explanation: 11ec2b69_c0d1_10d5_8f63_b335cd83b464_MD0005_00 Insured patients' out-of-pocket spending on covered health care services-known as cost-sharing-can vary significantly depending on the insurance plan. Each plan generally requires patients to spend a minimum amount out-of-pocket, known as the deductible, before covering expenses. After meeting the plan deductible, patients may still incur additional cost-sharing for in-network services. Examples of patient cost-sharing include copayments (ie, copays, a fixed amount per service, such as an office visit) and coinsurance (ie, a fixed percentage of the cost of a health care service, such as a hospital stay). In this case, the patient has already met her annual deductible of $3,000 (ie, she paid $3,000 this year to other providers for covered health care services) (Choice D). Her responsibility for the $1,000 urgent care bill depends on her plan's out-of-pocket maximum, describing the patient's annual cost-sharing limit: If her deductible equals her out-of-pocket maximum (eg, both are $3,000), the patient has already reached her maximum cost-sharing limit by meeting the deductible, so her plan would be required to pay 100% of this bill. If her deductible is less than her out-of-pocket maximum (eg, her deductible is $3,000, but her out-of-pocket maximum is $5,000), the patient has not reached the plan's maximum cost-sharing limit yet and would likely have to pay at least part of the bill. For example, the patient may be required to pay co-insurance (eg, a percentage, such as 20%, of the urgent care bill) (Choice A) Workers' compensation (in which employers, not insurance plans, pay for an employee's health care services) may be appropriate if the patient had sustained the injury directly due to her job environment. This patient injured her ankle during a voluntary, recreational activity; therefore, employer payment would be inappropriate. (Choice B) Some insurance plans incentivize patients to seek care at in-network facilities by offering lower copayment or coinsurance rates. However, even with in-network status, the out-of-pocket maximum and cost-sharing responsibilities above the deductible may still apply. Educational objective: Patients must spend an annual deductible (ie, minimum out-of-pocket payment) before insurance begins to cover services. Patients may still incur cost-sharing above the deductible depending on a plan's annual out-of-pocket maximum (ie, maximum limit on patient out-of-pocket spending).

Question 14

A 47-year-old woman comes to a multidisciplinary community health center.  She is uninsured, and the center's social worker counsels the patient regarding options for insurance enrollment.  The patient reports high levels of stress due to financial constraints and the recent deaths of her sister and mother from breast cancer.  She wishes to establish care with a primary care physician to be screened for breast cancer and discuss cancer prevention.  The patient is eligible to enroll in a private health insurance plan through the Health Insurance Marketplace exchange.  She states, "Every dollar counts right now.  I'm scared the doctor will charge me a big fee to get a mammogram."  Which of the following best describes this patient's expected out-of-pocket spending to obtain a mammogram?

Accepted Answer

Explanation: Uninsured individuals who do not qualify for federal health insurance programs (eg, Medicaid) and lack affordable access to private insurance plans (eg, due to unemployment) can purchase insurance through the Health Insurance Marketplace ("exchange"), which was established by the Affordable Care Act and operated by the federal government (with varying state involvement). According to the Affordable Care Act, insurance plans must adhere to the following regulations: Plans cannot deny coverage or increase premiums (ie, monthly insurance payment) due to a patient's preexisting health conditions (eg, history of diabetes or cancer) Plans must cover essential health benefits, a list of 10 services (eg, prescription drugs, mental health). Depending on the plan, patients may still incur out-of-pocket spending such as copays (ie, fixed cost of service) or coinsurance (ie, fixed percentage of service cost) on certain essential health benefits. However, for preventive services (eg, screening mammogram), insurance must cover all costs so that patients have zero out-of-pocket spending (eg, no copay or coinsurance). These rules apply to all Marketplace plans, regardless of insurance type (eg, Health Maintenance Organizations, Preferred Provider Organizations) and annual deductible (ie, amount patient spends out of pocket before insurance coverage begins). Therefore, this patient's expected out-of-pocket spending for a mammogram is zero on any health insurance plan (Choice A). (Choice C) The patient's income may allow her to receive subsidies to offset the monthly premium but does not influence the expected copays (ie, zero) for mammograms. (Choice D) Because insurance would cover the full cost of the mammogram, this patient will spend more if she chooses to self-pay. Educational objective: Federal law mandates that insurance plans cover 100% of costs associated with preventive health care services (eg, screening mammogram), so that patients incur zero out-of-pocket spending (eg, no copay).

Question 15

A 24-year-old man comes to the office for a follow-up visit.  His paternal grandfather died at age 45 from Huntington disease.  The patient says, "I don't know if my father has the condition because whenever I bring it up he shuts down and doesn't want to talk about it.  I know that if my father has the disease I could be at risk and so could my sister, who is 2 years younger.  I don't want to spend the next 20 years worrying about whether I will get sick."  The physician educates the patient about the course and genetics of Huntington disease and orders genetic testing at the patient's request.  The results are positive for Huntington disease.  Despite the physician's recommendation that the patient consider disclosing these results to family members, he refuses, stating that he prefers to keep this information from his family, which includes his father, sister, and wife.  The patient explains that he doesn't want them to worry.  Which of the following is the most appropriate course of action?

Accepted Answer

Explanation: According to American Medical Association guidelines (Opinion 2.131-Disclosure of Familial Risk in Genetic Testing), the primary duty of physicians is to protect confidential genetic information, but they should also identify circumstances under which they would expect patients to notify biological relatives. According to the American Society of Human Genetics, if attempts to encourage disclosure by the patient have failed, then disclosure of genetic information to relatives is permissible only if such a disclosure would serve to ameliorate or prevent a highly likely and forseeable harm to the identified individual. In this patient's situation, informing his family members about Huntington disease would not be expected to prevent or ameliorate harm, as his disease status does not change the disease's incurable nature or modify its course in his relatives (Choices A and C). Many patients initially respond to genetic testing results with feelings of shock, anxiety, or denial that may play a role in the initial decision of whether to disclose results to family members. Therefore, it is recommended that patients be counseled regarding options for disclosure prior to the testing itself, if possible. In this case, the physician should first discuss with this patient his reasons for nondisclosure and the risks and benefits of this decision. Although the physician should encourage disclosure, the patient's decision not to disclose should be respected. (Choice B) The physician should continue to encourage the patient's disclosure to his wife so that she can understand his condition and its impact on future planning if they desire children. However, the patient's genetic information should not be disclosed without his consent. (Choice D) Agreeing with the patient's decision would likely send a conflicting message after the physician has recommended disclosure to affected family members. It would be appropriate to provide emotional support to the patient, but he should be encouraged to disclose his condition to family members as the information can help with their understanding and ability to support him and may affect their desire for testing. Educational objective: Patients may respond to hereditary testing results with shock, anxiety, or denial. If a patient with positive results refuses to disclose the information to family members, the physician should discuss the reasons for the patient's decision in a supportive manner. The physician is obligated to report results only if harm to an identifiable individual is evident. References: Disclosures of Huntington disease risk within families: patterns of decision-making and implications. (http://www.ncbi.nlm.nih.gov/pubmed/17632780)

Question 16

An 80-year-old Caucasian female is being discharged from the hospital after surgical repair of the right hip fracture.  She fractured her right hip after falling down the steps in her home.  She has a past history of osteoporosis, hypertension controlled with thiazide diuretics and metoprolol, diabetes mellitus treated with metformin, and hypercholesterolemia controlled with simvastatin.  She suffered from an acute myocardial infarction six years ago, but she has not had any complications or recurrence of symptoms.  She has a 50-year-old daughter who lives near her house.  You advise the patient to consider an alternate living arrangement; however, she clearly expresses her desire to live by herself in her own home.  She does not want to live in her daughter's house or in a nursing home.  Which of the following is the most appropriate next step?

Accepted Answer

Explanation: Falls are a common cause of morbidity and mortality in the elderly population. These are associated with injuries and fractures, significant decline in functional status, and subsequent greater chance of nursing home placement. Falls in the elderly population occur as a result of a mixture of intrinsic and extrinsic factors. The intrinsic factors include any acute illness or an age-related decline in balance, vision, ambulation, proprioception, cognitive impairment, musculoskeletal or cardiovascular function. Some of the extrinsic stressors that can lead to an increased risk of falls include the use of multiple medications, psychotropic medications, and an unsafe home environment. Prevention of recurrent falls and the associated complications is important in patients with a history of prior falls. Some interventions that have been proven to be useful in the prevention of falls include muscle strength and balance training, withdrawal of psychotropic medications, and home hazard evaluation and modification by a trained professional. Therefore, the patient in the above vignette should have a total assessment and modification of her home environment to reduce the risk of subsequent falls. (Choices A, B & E) The patient appears competent and does not wish to live in the nursing home or with her daughter. She should not be forced by the physician or her daughter to move to the nursing home or her daughter's house. Educational Objective: Some interventions that have been proven to be useful in the prevention of falls in elderly patients include muscle strength and balance training, withdrawal of psychotropic medications, and home hazard evaluation and modification by a trained professional.

Question 17

A 41-year-old man is brought to the emergency department by ambulance after a motor vehicle accident.  He was driving a car with his 6-year-old daughter in the back seat when they were broadsided by a large truck traveling at high speed.  The patient is conscious during transit to the emergency department.  He appears oriented to date and time, and informs paramedics that he is a Jehovah's Witness and does not want blood transfusions for himself or his daughter.  Soon after, he begins moaning and writhing and is clearly in distress.  He complains of feeling nauseated and thirsty.  A facemask is placed to administer 100% oxygen.  Initial assessment indicates his temperature is 37 C (98.6 F), blood pressure is 100/58 mm Hg, pulse is 132/min and thready, and respirations are 34/min.  There are numerous lacerations on his scalp, trunk, abdomen, and extremities.  The patient's skin is cool and clammy.  Chest auscultation shows tachypnea and tachycardia but is otherwise normal.  His abdomen is diffusely tender to palpation and guarding is present.  Rectal examination is normal.  The patient's blood pressure begins to drop rapidly and approaches 60/15 mm Hg.  The trauma surgeon advises that an immediate exploratory laparotomy is warranted to ascertain the source of the internal bleeding.  Hemoglobin is 5.5 g/dL. 
Given the circumstances, which of the following is the most appropriate next step?

Accepted Answer

Explanation: It is important that medical personnel honor the principle of patient autonomy when competent adult Jehovah's Witnesses indicate that they do not want to receive blood transfusions. However, other supportive measures should be implemented whenever possible to maximize the likelihood of a successful outcome. For instance, some surgeries can be performed successfully using blood-sparing techniques or erythropoietin. Similarly, in cases of blood loss, intravenous fluids and vasopressors should be used. (Choices B and D) Because the patient is a competent adult, it is inappropriate to seek the permission of his wife or the courts for a blood transfusion. The patient has already made his wishes clear. In addition, seeking permission from his wife or the courts is impractical due to the urgency of his condition. (Choice C) Halting all further intervention would be premature, as the administration of intravenous fluids and vasopressors may stabilize this hypotensive patient. (Choice E) Ordering a blood transfusion in this patient would be in direct violation of his wishes and therefore invites litigation. However, had the patient been unconscious (and his desire to avoid blood products unknown), medical personnel would not have been held legally liable for proceeding with an immediate transfusion. Educational objective: Intravenous fluids and vasopressors are important supportive measures that should be administered to Jehovah's Witnesses who have suffered significant blood loss. References: Jehovah's Witnesses in the emergency department: what are their rights? (http://www.ncbi.nlm.nih.gov/pubmed/16299196)

Question 18

A 46-year-old truck driver comes to the office due to fatigue.  He has consumed energy drinks during the past 3 months to complete his driving routes.  He sleeps most of the day on weekends and avoids his wife and kids.  The patient says, "I even slept through my son's baseball game.  I felt really bad about that."  He has a history of chronic back and knee pain due to a motorcycle accident.  The patient's medications include naproxen.  He drinks a few beers with friends but has not socialized much lately.  The patient's wife says that he is never there for her and they fight constantly.  He has no history of manic symptoms or other psychiatric history.  Physical examination and routine laboratory studies are unremarkable.  Mental status examination shows depressed mood and sad affect.  The patient says he has had thoughts of suicide but would never do anything because of his children.  He is diagnosed with depression and started on sertraline.  He returns for a 3-week follow-up, reporting little change.  The patient says, "Some days I think I'm feeling a little better, but other days are really bad.  I don't know about these pills.  I've been taking them and don't have any side effects, but I still feel pretty bad." 
Which of the following is the most appropriate response?

Accepted Answer

Explanation: This patient has symptoms of major depressive disorder (ie, depressed mood, fatigue, sleep disturbance, decreased interest in socializing, suicidal ideation) and is treated appropriately with a selective serotonin reuptake inhibitor (sertraline). However, 3 weeks is an inadequate trial (<6 weeks), making it premature to assess his response to the medication at this follow-up. The physician should educate the patient that a full trial for antidepressants is 6 weeks and encourage him to continue taking the medication. Switching the medication or augmenting it with another (Choices C and D) is not indicated. (Choice A) Nonadherence should always be considered in patients who are not responding to medication. However, this patient states that he is taking the medication, and there is no reason to suspect that he is unreliable. (Choice E) Although it may be beneficial to add psychotherapy to the patient's treatment, discontinuing his antidepressant after an inadequate trial of 3 weeks is not appropriate. Educational objective: An inadequate trial (<6 weeks) is a common cause of a patient's poor response to antidepressant medication. Patients should be educated that antidepressants take time to work and be encouraged to complete a full trial before considering other treatment options. References: When should you move beyond first-line therapy for depression? (http://www.ncbi.nlm.nih.gov/pubmed/20977871)

Question 19

An 82-year-old man is admitted to the hospital after an out-of-hospital cardiac arrest.  He was successfully resuscitated and intubated in the field by paramedics and transferred to the hospital's intensive care unit.  On day 3 of hospitalization, he remains minimally responsive to most stimuli.  The hospital has the patient's advance directive on file, which clearly states that the patient does not want life-sustaining treatment, including mechanical ventilation.  The patient's wife agrees with the advance directive and wants to withdraw life support.  The rest of the family, including a son and 2 daughters from a previous marriage, become very upset with her decision and strongly oppose the withdrawal of life support.  They claim that their father's wife "never really cared for him and married him only for his money."  They would like to continue mechanical ventilation to see if their father's condition improves.  Despite multiple meetings with all family members in an attempt to reach a mutual decision, the patient's children and wife continue to disagree about management.  Which of the following is the most appropriate next step in management of this patient?

Accepted Answer

Explanation: The principle of patient autonomy requires that the physician respect the patient's decision to withhold or withdraw life-sustaining treatment. A competent adult patient may, via an advance directive, formulate and provide valid consent to withhold or withdraw life-supporting treatment in the event that any injury or illness renders that individual incapable of making such a decision. In this case, there is an advance directive clearly stating the patient's wishes; therefore, life support should be withdrawn. This patient's decision to not have mechanical ventilation, as outlined in the advanced directive, overrides the wishes of all family members. The physician should attempt to explain the patient's wishes to the children and help them come to terms with their father's decision. (Choices A and C) The use of courts or an ethics committee to resolve disputes regarding withdrawal of life support is necessary only when there is no advance directive. (Choice D) The wife's motives are irrelevant. The children should be informed that it is their father's wishes, as stated in his advance directive, that must be honored. (Choice E) Life support should be withdrawn because it is the patient's wish as documented in his advance directive, not because his wife is his next of kin. In cases in which there is no advance directive and the patient lacks decision-making capacity, the patient's spouse (not the children) would have priority in making a substituted judgment regarding what the patient would have wanted. Educational objective: Patient preference, as outlined in advance directives, should always prevail in the case of any family conflict regarding the withdrawal of life support. References: Advance directives: empowering patients at the end of life. (http://www.ncbi.nlm.nih.gov/pubmed/25286366) Advance care planning: a systematic review of randomised controlled trials conducted with older adults. (http://www.ncbi.nlm.nih.gov/pubmed/27451328)

Question 20

A 46-year-old truck driver comes to the office due to fatigue.  He has consumed energy drinks during the past 3 months to complete his driving routes.  He sleeps most of the day on weekends and avoids his wife and kids.  The patient says, "I even slept through my son's baseball game.  I felt really bad about that."  He has a history of chronic back and knee pain due to a motorcycle accident.  The patient's medications include naproxen.  He drinks a few beers with friends but has not socialized much lately.  The patient's wife says that he is never there for her and they fight constantly.  He has no history of manic symptoms or other psychiatric history.  Physical examination and routine laboratory studies are unremarkable.  Mental status examination shows depressed mood and sad affect.  The patient says he has had thoughts of suicide but would never do anything because of his children.  He is diagnosed with depression and started on sertraline.  He returns for a 3-week follow-up, reporting little change.  The patient says, "Some days I think I'm feeling a little better, but other days are really bad.  I don't know about these pills.  I've been taking them and don't have any side effects, but I still feel pretty bad."
Additional history shows that the patient was drinking 4 or 5 beers at the end of the day to help him fall asleep.  He also obtained amphetamine/dextroamphetamine and some oxycodone pills from a friend and used these daily to manage his back pain and stay alert during his most recent road trip.  The physician counsels the patient on the adverse effects of substance use and explains how alcohol, stimulants, and opiates may be contributing to his symptoms.  The patient says he plans to take a medical leave of absence from work and abstain from alcohol, stimulants, and pain medications.  He continues taking sertraline for his depression.  At the patient's next follow-up a month later, he is doing well and not using any alcohol, stimulants, or opiates.  His depression has improved, and he is attending Alcoholics Anonymous meetings.  The physician receives a letter from the patient's employer asking when he can return to work and if there are any restrictions or safety concerns.  The patient has signed a release of information.
Which of the following would be the most appropriate response to the employer?

Accepted Answer

Explanation: This patient has signed a release of information authorizing the physician to provide information to the employer. Although the physician must respond to the employer's request (Choice A), he also must adhere to a fundamental principle of the Health Insurance Portability and Accountability Act Privacy Rule that requires "minimum necessary" disclosure. This patient is currently doing well with no evidence of depression or substance use. Protecting confidentiality is important, and the physician should provide only the minimum information necessary to address the employer's questions about this patient's medical status and ability to return to work. (Choices B, D, and E) Disclosing (or suggesting) that the patient is being treated for depression or has ongoing issues with substance use or medication nonadherence is inappropriate. Employers are not entitled to receive non-employment-related medical information, and they do not need to know the employee's diagnosis, except in limited cases when public safety is in imminent danger. Commercial driver's licensing requires that employers follow alcohol and drug testing rules. Although random urine drug testing is indicated given this patient's job, it would not be appropriate for the physician to recommend it as it implies that the patient might be using. Educational objective: The Health Insurance Portability and Accountability Act (HIPAA) requires a patient to give the physician written authorization before protected health information can be disclosed to an employer. The HIPAA Privacy Rule limits disclosure to the "minimum necessary" information required to complete a request for information. References: HIPAA privacy rules and compliance with federal and state employment laws: the participant authorization form. (http://www.ncbi.nlm.nih.gov/pubmed/12645240)

Exam 1: Advanced Clinical Medicine