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Old 06-25-2011
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Medicolegal and Ethics acute abdomen with pt refusing tx due to lack of insurance

A 19-year-old woman arrives via ambulance to the emergency room of a large private hospital with severe abdominal pain. The patient's best friend called an ambulance to take her to the hospital despite her objections when she was found on the ground writhing in pain. On arrival, she states that she will be fine and is staunchly refusing medical care. Her best friend says that the reason for the refusal is because they live in a boarding house and does not have funds to pay for a hospital stay. What is the most appropriate next step in the management of this patient?

Answer Choices
A. Document refusal in chart and obey the patient's wishes
B. Inform her of the hospital's legal obligations to treat her
C. Offer her a transfer to a local indigent hospital
D. Proceed with medical evaluation and surgery, if necessary
E. Provide her with pain relief and reassess her in an hour
F. Referral to the hospital social worker
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Old 06-25-2011
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Default D

I would proceed with medical assessment first. She probably has acute surgical abdomen.

I choose D!
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Old 06-25-2011
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confuse between B and D
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Old 06-25-2011
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option B is a little confusing according to my knowledge no hospital can turn away a patient who come in in an emergency situation weather they can pay for treatment or not.
So does B me that they have to treat her even if she cant pay or does it mean they have to treat her even if she doenst want the treatment cuz if it means the first then its correct if its the 2nd then its totally wrong.


I feel D is wrong as we cant start treatment or anything unless she agrees with it as according to the question she is refusing treatment so we cant do an assesment or surgery unless she says we can.

as for A i dont think its right either as she doesnt know about her right to treatment. Once she knows about that and she still refuses then the hospital can discharge her

option C seems like a cop out ie like calling in for a consult or sending her to another doctor something which is almost never right in the steps exam

E- again cant be done unles the pt agrees with it which acording to the question the patient doenst yet

F- will definitly need to be done but i think its for later after completing option B and starting her treatment.
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Old 06-25-2011
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Option B (Inform her of the hospital's legal obligations to treat her) is correct. The Emergency Medical Treatment & Labor Act states that a patient arriving at any emergency room has the right to be physically examined and receive stabilizing treatment regardless of their ability to pay for services. If examination and treatment are refused, informing the patients of her legal rights is the first step necessary to document informed refusal.

Option A (Document refusal in chart and obey the patient's wishes) is incorrect. There are numerous steps that must be taken to obtain informed refusal, the first of which is to inform her of her rights under the law to receive examination and stabilizing treatment.

Option C (Offer her a transfer to a local indigent hospital) is incorrect. The emergency room to which she presents is legally obliged to provide her with a screening examination and any stabilizing treatment prior to transferring to another hospital. She may have a ruptured ectopic pregnancy and transferring to another hospital could cost her her life.

Option D (Proceed with medical evaluation and surgery, if necessary) is incorrect. Implied consent in an emergency situation is not valid in this situation because she is lucid and no life-threatening condition has been identified.

Option E (Provide her with pain relief and reassess her in an hour) is incorrect. Pain relief would be inappropriate prior to evaluation or complete documentation of informed refusal.

Option F (Referral to the hospital social worker) is incorrect. This would be inappropriate at this stage, because she has a right to be screened and stabilized regardless of her ability to pay.

High-yield Hit 1
The concept of informed consent may be derived from both respect for the principle of autonomy and from a desire to protect patients and research subjects from harm. There is general agreement that consent must be genuinely voluntary and made after adequate disclosure of information. As a minimum, when a patient consents to a procedure in health care, she should be informed about the expectation of benefit as well as the other reasonable alternatives and possible risks that are known. Table 1-2 provides a useful checklist (PREPARED) that expands on the minimum information to include the reason or rationale for the procedure, any appropriate patient preferences (e.g., avoiding surgery or a long course of medication), and the expenses involved in having the procedure.

From Essentials of Obstetrics & Gynecology 4E by Hacker et al
High-yield Hit 2
Table 1-2. The PREPARED system: A checklist to assist patient and provider in the process of informed consent
Procedure The course of action being considered
Reason The indication or rationale
Expectation The chances of benefit and failure
Preferences Patient-centered priorities (utilities) affecting choice
Alternatives Other reasonable options
Risks The potential for harm from procedures
Expenses All direct and indirect costs
Decision Fully informed collaborative choice
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