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A 68-year-old man undergoes a complex surgical lung transplant. Prior to the procedure, his surgeon explains the procedure and the postoperative recovery process. After hearing these details, the patient provides informed consent. The subsequent transplant operation proves more difficult than anticipated and resulting complications leave the patient in a coma. Respiratory function is facilitated by mechanical ventilation, as is standard procedure following this type of surgery. The opinion of the surgeon and other consulting physicians is that the chance of the patient's recovery is good, although uncertain. At this point, the man's son presents a living will, signed by the patient and containing the signatures of two witnesses. The living will states that, should the situation arise, the patient would not wish to be kept alive by mechanical means. Based on this living will, the son asks to have mechanical ventilation terminated at once stating, "This is my father's wish." The patient's wife, on the other hand, asks that life support be maintained indefinitely because she "cannot bear the thought" of losing her husband. This case will most likely be resolved by which of the following?
A. A court ruling to adjudicate the validity of the living will.
B. A ruling by the hospital ethics committee as to the proper ethical course of action.
C. Consultation among family members to achieve a family consensus as to how to proceed.,
D. Consultation with the patient's primary care physician
E. Maintaining the patient on life support indefinitely.
F. Maintaining the patient on life support based on the patient's consent until such time as it is determined that the chance of recovery is unlikely
G. Maintaining the patient on life support based on the patient's wife's request until such time as she changes her mind.
H. Terminating life support as the living will requests.
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f
1. pt is in comma it is not with brain death
2. chance of recovery is good
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HHH..good god where r these questions from raji, if they give such huge ones we r doomed
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agree with elba..change to F :d
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yeah i know these are very long questions... and scary too..
i too want to know, if they have such long questions in real exams... but good for practise, u get many explanations in single Q
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oh yea..very gud for learning can`t appreciate enough
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elba u got it right...
The correct answer is F. The subtle, but important point, in this question is that the life support procedures are part of the standard postoperative recovery procedures to which the patient consented when he agreed to the transplant. In other words, this is not a case of the patient's life being prolonged by life support. Rather, the life support is key part to the treatment. Note that life support will not be maintained indefinitely. Should prognosis change so that recovery is unlikely, then the living will comes into play and life support would be terminated.
The patient has already consented to the treatment. Court examination (choice A) of the living will would add nothing. Given the consent and the chance of recovery, this is not a situation in which the living will is germane.
The ethics board (choice B) can add nothing here. There is ample information in the case for the physician to make an on-the-spot decision. In general, going to court or to the ethics committee will not be correct answers on the Step 1 exam.
The patient, not a committee of family members (choice C), has the right to decide what should be done. The patient's consent to the surgery is the governing principle for now. If recovery should seem unlikely, then the living will comes into play. In neither circumstance is a joint decision of family members relevant.
If the patient's consent were not already obtained and there was no clear statement of the patients wishes as in the living will, then consulting with the patient's primary care physician (choice D) might make sense. The primary care physician may have (should have) discussed end-of-life care issues with this patient and may be a window into the unconscious patient's true wishes. In this case, with other information available, the consultation with the primary care physician will yield nothing new.
If at some point, recovery seems unlikely, then the life support is no longer a part of postoperative procedure, but is in fact the sort of life-sustaining effort that the patient asked to avoid in his living will. Life support should not be indefinite (choice E), but should be terminated when the prognosis changes for the worse.
The issue here is not the wife's wishes (choice G), but the patient's consent to mechanical support as a part of postoperative recovery. Remember that spouses are only relevant in so far as they represent the wishes of their partners. We act, not on her wishes, but only on his.
Choice H is incorrect. The mechanical ventilation is a standard part of postoperative recovery to which the patient has consented. Once begun, the process must be completed. Remember patients do not consent to each actual movement of the scalpel, but to the operation itself. It is the physician's
job to know the technical steps needed to bring the treatment to a successful conclusion
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