Kk&s Ch.57, 58, 59

Front 1

In a, a patient who is mentally competent gives specific instructions that doctors must follow when the patient cannot communicate them because of illness. These instructions may include rejection of feeding tubes, artificial airways, or any other measures to prolong life

Back 1

living will

Front 2

Also known as ? the? gives another person the power to make medical decisions if the patient cannot do so. That person, also known as the surrogate, is empowered to make all decisions about terminal care on the basis of what he or she thinks the patient would want.

Back 2

Also known as durable power of attorney, the health care proxy gives another person the power to make medical decisions if the patient cannot do so. That person, also known as the surrogate, is empowered to make all decisions about terminal care on the basis of what he or she thinks the patient would want.

Front 3

Today, patients who have left no advance directives or who are legally incompetent to do so have access to ?

Back 3

hospital ethics committees

Front 4

Highest stress level for caregiver fatigue?

Back 4

The highest stress level was found in families who cared for a terminally ill patient at home, especially when death occurs in the home, and realized in retrospect that they would have preferred an environment in which death occurs in the presence of skilled caretakers.

Front 5

The distinctions are important because they call for different treatment strategies; ? and ? pain are responsive to opiates, whereas ? and ? maintained pain may require adjuvant medications in addition to opiates.

Back 5

The distinctions are important because they call for different treatment strategies; somatic and visceral pain are responsive to opiates, whereas neuropathic and sympathetically maintained pain may require adjuvant medications in addition to opiates.

Front 6

Usually, but not always constant, aching, gnawing, and well localized (e.g., bone metastases)

Back 6

Somatic Pain
()

Front 7

Usually, but not always constant, deep, squeezing, poorly localized, with possible cutaneous referral (e.g., pleural effusion leading to [1] deep chest pain, [2] diaphragmatic irritation referred to shoulder)

Back 7

Visceral Pain
()

Front 8

Burning dysesthetic pain with shock-like paroxysms associated with direct damage to peripheral receptors, afferent fibers, or central nervous system (CNS), leading to loss of central inhibitory modulation and spontaneous firing (e.g., phantom limb pain; can involve sympathetic somatic afferents)

Back 8

Neuropathic Pain

Front 9

ariable characteristics, secondary to psychological factors in the absence of medical factors; rare as a pure phenomenon in patients with cancer, but often an additional factor in the presence of organic pain

Back 9

Psychogenic Pain

Front 10

A frequent mechanism of psychotoxicity is the accumulation of drugs or metabolites whose duration of analgesia is shorter than their plasma half-life (???)
List 3 opiods

and better choice

Back 10

morphine, levorphanol [Levo-Dromoran], and methadone [Dolophine])

hydromorphone (Dilaudid), which have half-lives closer to their analgesic duration, can relieve the problem without loss of pain control.

Front 11

What is recommended:
maintenance or prn dosing?

Back 11

Maintenance dosing improves pain control, increases drug efficiency, and relieves patient anxiety, whereas as-needed orders allow pain to increase while waiting for the drug to be given. Moreover, as-needed analgesia administration perversely sets up the patient for staff complaints about drug-seeking behavior.

Front 12

when changing a patient from intramuscular to oral morphine use, the intramuscular dose must be multiplied by ? to avoid causing the patient pain and provoking drug-seeking behavior.

Back 12

6

Front 13

Many adjuvant drugs used for pain are psychotropics with which psychiatrists are familiar, but in some cases, their analgesic effect is separate from their primary psychotropic effect. Commonly used adjuvants include

Back 13

antidepressants,
mood stabilizers (e.g., gabapentin)
phenothiazines,
butyrophenones,
antihistamines,
amphetamines, and
steroids.

Front 14

Sources of distress include psychiatric symptoms, such as anxiety, and physical symptoms. Foremost among physical symptoms are those involving the

Back 14

gastrointestinal system, including diarrhea, constipation, anorexia, nausea, vomiting, and bowel obstruction.

Front 15

After accidents, ? is the second most common cause of death in children

Back 15

cancer

Front 16

Children require more support than adults in coping with death. On average, a child does not view death as permanent until the age of about ?

before that, death is viewed as ??

Back 16

10

a sleep or separation.

Front 17

To help guide clinicians facing requests for physician-assisted suicide, the AMA's Institute for Ethics has proposed the following eight-step clinical protocol:

Back 17

*
Evaluation of the patient for depression or other psychiatric conditions that could cause disordered thought
*
Evaluation of the patient's “decision-making competence”
*
Discussion with the patient about his or her goals for care
*
Evaluation and response to the patient's “physical, mental, social, and spiritual suffering”
*
Discussion with the patient about the full range of treatment and care options
*
Consultation by the attending physician with other professional colleagues
*
Assurance that care plans chosen by the patient are being followed, including removal of unwanted treatment and the provision of adequate pain and symptom relief
*
Discussion with the patient explaining why physician-assisted suicide is to be avoided and why it is not compatible with the principled nature of the care protocol

Front 18

In almost every case in which a patient asks to be put to death, a triad exists of

Back 18

depression associated with an

incurable medical condition that causes the patient
intolerable pain

Front 19

Informed consent: info to disclose (5)?

Back 19

1. Diagnosis—description of the condition or problem
2. Treatment—nature and purpose of proposed treatment
3. Consequences—risks and benefits of the proposed treatment
4. Alternatives—viable alternatives to the proposed treatment including risks and benefits
5. Prognosis—projected outcome with and without treatment

Front 20

How much wine does California produce for America?

Back 20

90%

Front 21

? is the right to maintain secrecy or confidentiality in the face of a subpoena.

Back 21

Privilege

Front 22

The right of privilege belongs to the ?

Back 22

The right of privilege belongs to the patient, not to the physician, and so the patient can waive the right.

Front 23

It is estimated that at least ? to ? percent of patients and perhaps as high as ? percent of patients treated with neuroleptic drugs for more than 1 year exhibit some tardive dyskinesia.

These figures are even higher for ?

Back 23

It is estimated that at least 10 to 20 percent of patients and perhaps as high as 50 percent of patients treated with neuroleptic drugs for more than 1 year exhibit some tardive dyskinesia.

elderly patients.

Front 24

The law tends to assume that suicide is preventable if it is ?

Back 24

foreseeable

Courts closely scrutinize suicide cases to determine if a patient's suicide was foreseeable. Foreseeability is a deliberately vague legal term that has no comparable clinical counterpart, a common-sense rather than a scientific construct. It does not (and should not) imply that clinicians can predict suicide. Foreseeability should not be confused with preventability, however. In hindsight, many suicides seem preventable that were clearly not foreseeable.

Front 25

In the landmark case ? v. Regents of the University of California, the California Supreme Court ruled that mental health professionals have a duty to protect identifiable, endangered third parties from imminent threats of serious harm made by their outpatients.

Back 25

Tarasoff

Front 26

Difference between Tarasoff I and II?

Back 26

In 2, added duty to protect along with warn ... sorta unclear

Front 27

Psychiatrists may be asked to evaluate patients' testamentary capacities or their competence to make a will. Three psychological abilities are necessary to prove this competence.

Back 27

Patients must know the nature and the extent of their bounty (property),

the fact that they are making a bequest,
and the identities of their natural beneficiaries (spouse, children, and other relatives).

Front 28

Explain competence assessment?

Back 28

Competence is determined on the basis of a person's ability to make a sound judgment—to weigh, to reason, and to make reasonable decisions. Competence is task specific, not general; the capacity to weigh decision-making factors (competence) often is best demonstrated by a person's ability to ask pertinent and knowledgeable questions after the risks and the benefits have been explained.

. Although physicians (especially psychiatrists) often give opinions on competence, only a judge's ruling converts the opinion into a finding; a patient is not competent or incompetent until the court so rules.

Front 29

Competence to stand trial based on?

Back 29

Dusky v. United States, approved a test of competence that seeks to ascertain whether a criminal defendant “has sufficient present ability to consult with his lawyer with a reasonable degree of rational understanding—and whether he has a rational as well as factual understanding of the proceedings against him.”

Front 30

M'Naghten rule, which, until recently, has determined criminal responsibility in most of the United States, holds that persons are

Back 30

not guilty by reason of insanity if they labored under a mental disease such that they were
unaware of the nature, the quality, and the consequences of their acts or

if they were incapable of realizing that their acts were wrong

Front 31

ccording to the M'Naghten rule, the question is not whether the accused knows the difference between right and wrong in general, it is whether the defendant understood the

Back 31

nature and the quality of the act and whether the defendant knew the difference between right and wrong with respect to the act—that is, specifically whether the defendant knew the act was wrong or perhaps thought the act was correct, a delusion causing the defendant to act in legitimate self-defense.

Front 32

? paternalism is acting beneficently when the patient's impaired faculties prevent an autonomous choice. ? paternalism is acting beneficently, despite the patient's intact autonomy.

Back 32

Weak paternalism is acting beneficently when the patient's impaired faculties prevent an autonomous choice. Strong paternalism is acting beneficently, despite the patient's intact autonomy.

Front 33

Guidelines have been proposed for permitting beneficence to overrule patient autonomy

Back 33

hen the patient faces substantial harm or risk of harm, the paternalistic act is chosen that ensures the optimal combination of maximal harm reduction, low added risk, and minimal necessary infringement on patient autonomy

Front 34

List nonsexual boundaries?

Back 34

business relationship
idealogy: respect pts choice
social friendship with pt
financial: arrange fee's before starting therapy
confidentiality:

Front 35

How can psychiatrists avoid being charged with patient abandonment on retirement?

Back 35

Retiring psychiatrists are not abandoning patients if they provide their patients with sufficient notice and make every reasonable effort to find follow-up care for the patients.

Front 36

A dying patient bequeaths his or her estate to his or her treating psychiatrist. Is this ethica

Back 36

No. Accepting the bequest seems improper and exploitational of the therapeutic relationship. However, it may be ethical to accept a token bequest from a deceased patient who named his or her psychiatrist in the will without that psychiatrist's knowledge.

Front 37

Is it ethical for psychiatrists to perform vaginal exams? Hospital physicals?

Back 37

Psychiatrists may provide nonpsychiatric medical procedures if they are competent to do so and if the procedures do not preclude effective psychiatric treatment by distorting the transference. Pelvic exams carry a high risk of distorting the transference and would be better performed by another clinician.

Front 38

Can ethics committees review issues of physician competency?

Back 38

Yes. Incompetency is an ethical issue.

Front 39

Must confidentiality be maintained after the death of a patient?

Back 39

Yes. Ethically, confidences survive a patient's death. Exceptions include protecting others from imminent harm or proper legal compulsions.

Front 40

Is it ethical to release information about a patient to an insurance company?

Back 40

Yes, if the information provided is limited to that which is needed to process the insurance claim

Front 41

Can a videotaped segment of a therapy session be used at a workshop for professionals?

Back 41

Yes, if informed, uncoerced consent has been obtained, anonymity is maintained, the audience is advised that editing makes this an incomplete session, and the patient knows the purpose of the videotape.

Front 42

Should a physician report mere suspicion of child abuse in a state requiring reporting of child abuse?

Back 42

No. A physician must make several assessments before deciding whether to report suspected abuse. One must consider whether abuse is ongoing, whether abuse is responsive to treatment, and whether reporting will cause potential harm. Check specific statutes. Make safety for potential victims the top priority.

Front 43

Is there a potential ethical conflict if a psychiatrist has both psychotherapeutic and administrative duties in dealing with students or trainees?

Back 43

Yes. You must define your role in advance to the trainees or students. Administrative opinions should be obtained from a psychiatrist who is not involved in a treatment relationship with the trainee or student.

Front 44

Is it ethical for a supervising psychiatrist to sign a diagnosis on an insurance form for services provided by a supervisee when the psychiatrist has not examined the patient?

Back 44

Yes, if the psychiatrist ensures that proper care is given and the insurance form clearly indicates the role of supervisor and supervisee.

Front 45

Is it ethical to refuse to divulge information about a patient who has agreed to give this information to those requesting it?

Back 45

No. It is the patient's decision, not the therapist's.

Front 46

Is informed consent needed when presenting or writing about case material?

Back 46

Not if the patient is aware of the supervisory/teaching process and confidentiality is preserved.

Front 47

Should psychiatrists expose or report unethical behavior of a colleague or colleagues? Can a spouse bring an ethical complaint?

Back 47

Psychiatrists are obligated to report colleagues' unethical behavior. A spouse with knowledge of unethical behavior can bring an ethical complaint as well.

Front 48

What are the ethical requirements when a psychiatrist supervises other mental health professionals?

Back 48

The psychiatrist must spend sufficient time to ensure that proper care is given and that the supervisee is not providing services that are outside the scope of his or her training. It is ethical to charge a fee for supervision.