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Old 08-09-2013
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Help Ethics doubt

Source of info : Dr. Conrad Fischer's ethics book

please correct me if I am wrong.

consent for an emergency in an adult pt who has lost decision making capacity is implied if there is 1) no written advance directive ( living will/health care proxy) 2) no oral advance directive
( Basically when an INFORMED REFUSAL cannot be obtained )

DOUBT 1 : does substituted judgement also fall under this ?? can you not perform a life saving procedure/rx based on the family's assumptions of what pt WOULD HAVE WANTED IF HE WERE CONSCIOUS ??


DOUBT 2 : practice Q no 47 ( CF Ethics book ) : 22y/o m subdural hematoma & brain contusion. needs blood in order to have a necessary lifesaving surgery. his parents refuse to allow transfusion based on their religious beliefs.
what should be done ?
ANS is give the blood.

the explanation says " ONLY COMPETENT PT CAN REFUSE EMERGENCY LIFE SAVING PROCEDURES. CONSENT IS IMPLIED IN AN EMERGENCY UNLESS THERE IS A CONTEMPORARY REFUSAL BY A CONSCIOUS PT.

isn't this contradictory. I don't understand this.
please someone answer this. thanks.
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Old 08-09-2013
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Help Doubt 3

DOUBT 3 :

is this concept correct ??
you cannot not give blood to an unconscious pt who you know is a JEEVOHAH'S WITNESS unless that patient specifically stated the he/she does not want blood.. if there is no family/ advance directive you cannot assume that the pt does not want blood. and you should give lifesaving blood to an unconscious known jeevohah's witness pt if you cannot document INFORMED REFUSAL ??
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Old 08-09-2013
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pls tell me question numbers in 100 cases of cornard fischer?
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Old 08-09-2013
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Q 40, 47 & CHAP 5-end of life issues.
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Old 08-09-2013
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To reply to your second doubt, I don't understand what you find contradictory about it. Its a life saving procedure, hence you assume implied consent because there's no advanced directive from the patient, either written or oral. Parents don't have a say even for a minor, let alone a 22 year old.


With respect to doubt 3, yes you are right. Even if the patient is wearing a t shirt that says. "Jehovah's witness" you have to give the patient blood if its life saving if there is no advance directive. You can't make assumptions like that on the patients behalf.


What I've said above I'm quite sure about.


Regarding your first doubt, I believe in an emergency there's no question of what family believes the patient might have wanted. The doctor does what's the best for the patient to save his life, if there are no advanced directives.

This I'm not entirely sure about because 1. I'm not quite sure about what you're asking and 2. This is what I think is right, not based on anything I've read.
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Old 08-09-2013
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Help

thanks.

see there are 3 possibilities if an adult unconscious needs emergency rx
1) advance directive written ( proxy or living will )
2) oral advance directive ( family conveys pt's known wishes )
3) substituted judgement - family doesn't know the pt's wishes but makes decision based on what the pt would hv wanted..

so what I meant to ask was that can a family deny emerg treatment based on substituted judgement ?? ( eg an elderly pt not wanting a lumbar puncture for meningitis )

regarding doubt 2 : I dint frame it correctly. the q mentioned parents refuse emerg rx BASED ON THEIR RELIGIOUS BELIEFS. so u gotta give the pt blood bcoz parents' beliefs don't matter.

but in such a scenario ( with no written/oral advance directive) can parents refuse blood stating the child would not hv wanted based on his beliefs ?? !! ( I know no parent would do that, but its just a usmle concept I want to clear)
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Old 08-09-2013
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p.s. by child I meant 22 y/o male
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Old 08-09-2013
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OK, I got you. For doubt 1, family CANNOT deny patient life saving treatment based in substituted judgement. Assuming there's no advance directive. Substituted judgement would also work for non emergency decisions.


For doubt 2 its a similar concept, life saving decisions, if family goes against the life saving treatment, you go ahead and treat anyway. Parents have no say. Parents can refuse, doesn't mean you have to follow
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