Updated: 9/18/2019

Legal Principles

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Introduction
  • The following principles are intended to be applied only to a variety of individual situations you may face on the USMLE
Capacity, Competence, and Consent
  • Capacity vs competence 
    • capacity is a medical term
    • competence is a legal term
  • Competent patients have the right to refuse medical information and medical treatment(s)
    • a feeding tube is a medical treatment
    • a competent person can refuse lifesaving hydration or nutrition 
  • Assume that the patient is competent unless
    • history of suicide attempt
    • psychotic
    • patient cannot communicate
  • Obtain informed consent
    • patient must understand 
      • risks
      • benefits
      • alternatives
        • including no treatment
    • patient must agree with plan of care without coercion
    • exceptions
      • emergencies
      • waiver by patient
      • patient lacks decision-making capacity
      • therapeutic privilege
        • physician deprives an unconscious or confused patient of his autonomy in order to protect the patient's health (paternalism)
    • note that written consent can be revoked orally at any time
    • components of informed consent include:
      • patient makes and communicates a choice
      • patient is informed
        • information has not been withheld from the patient
      • decision remains stable over time
      • decision is consistent with patient's values and goals
      • decision is not result of delusions or hallucinations
      • consent implied in emergency situations without the healthcare proxy and patient unresponsive/confused 
    • consent from a patient's spouse is not required treatment of a patient with capacity
End-of-Life Issues
  • If the patient cannot make decisions, surrogate decision makers must use the following criteria:
    • subjective standard (advance directive of patient)
      • living will = patient provides specific instructions to withhold or withdraw life-sustaining treatment
    • substituted judgment (what would the patient want)
      • durable power of attorney = patient designates healthcare proxy to make decisions
      • supersedes living will if both exist
    • "best interests" of the patient
    • when no living will or durable power of attorney exists, the clinician is responsible for determining an appropriate surrogate decision maker from available family members
      • the priority of next-of-kin for surrogate decision making is as follows:
        • legal guardian appointed by a court
        • spouse
        • adult children (> 18 yrs)
        • parents
        • adult siblings 
        • grandparents/grandchildren
        • friend of the patient
  • Euthanasia
    • passively allowing patient to die is acceptable
      • but do everything you can to relieve patient's suffering
    • active killing of the patient is not acceptable
  • when treatment should stop
    • physician thinks treatment is futile but family insists on treatment
      • continue treatment
    • after declaraion of brain death but family insists on treatment
      • stop treatment
Confidentiality
  • Confidentiality between physician and patient is generally absolute  
    • exceptions
      • suspicion of child/elder abuse
      • gunshot or stabbing injuries must be reported to the police
      • communicable disease must be reported
      • the patient is a harm to others or self
        • tarasoff decision 
      • no alternative means exists to warn others
      • patient waves right to privacy
        • e.g., for insurance purposes
Minors
  • Minors cannot give informed consent unless emancipated through:
    • marriage
    • a parent
    • military service
    • living alone
  • A minor's refusal of treatment can be overruled by a parent
  • Parents cannot withhold life- or limb-saving treatment from their children, but can refuse other treatments
  • Examples
    • 17-year-old girl whose parents cannot be contacted
      • physician may treat a threat to health under in locum parentis
    • 17-year-old girl living on her own
      • patient can choose whether or not to give consent
    • 17-year-old girl who is requests birth control
      • provide access even in absence of parental consent
    • 16-year-old girl refuses but mother consents
      • treat
    • 16-year-old girl consents but mother refuses
      • do not treat
Other Principles
  • Avoid going to court
  • Use trained medical interpreters when possible
  • Committed mentally ill patients retain their rights
  • Never abandon a patient
    • transferring a patient to another physician's care is rarely (if ever) a correct answer on the USMLE
    • If a treatment (such as abortion, birth control, etc) is against a physician's personal beliefs - that physician does not have to provide that treatment; however, they are responsible for referring their patient to a provider who is willing and able to provide such care 
  • Disclose all errors, regardless of harm
    • consulting risk management alone is rarely (if ever) a correct answer on USMLE
Child and Elder Abuse
  • If suspected abuse is occurring, physicians are mandated reporters and MUST report to Child Protective Services or Adult Protective Services 
 

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Questions (6)
Lab Values
Blood, Plasma, Serum Reference Range
ALT 8-20 U/L
Amylase, serum 25-125 U/L
AST 8-20 U/L
Bilirubin, serum (adult) Total // Direct 0.1-1.0 mg/dL // 0.0-0.3 mg/dL
Calcium, serum (Ca2+) 8.4-10.2 mg/dL
Cholesterol, serum Rec: < 200 mg/dL
Cortisol, serum 0800 h: 5-23 μg/dL //1600 h:
3-15 μg/dL
2000 h: ≤ 50% of 0800 h
Creatine kinase, serum Male: 25-90 U/L
Female: 10-70 U/L
Creatinine, serum 0.6-1.2 mg/dL
Electrolytes, serum  
Sodium (Na+) 136-145 mEq/L
Chloride (Cl-) 95-105 mEq/L
Potassium (K+) 3.5-5.0 mEq/L
Bicarbonate (HCO3-) 22-28 mEq/L
Magnesium (Mg2+) 1.5-2.0 mEq/L
Estriol, total, serum (in pregnancy)  
24-28 wks // 32-36 wks 30-170 ng/mL // 60-280 ng/mL
28-32 wk // 36-40 wks 40-220 ng/mL // 80-350 ng/mL
Ferritin, serum Male: 15-200 ng/mL
Female: 12-150 ng/mL
Follicle-stimulating hormone, serum/plasma Male: 4-25 mIU/mL
Female: premenopause: 4-30 mIU/mL
midcycle peak: 10-90 mIU/mL
postmenopause: 40-250
pH 7.35-7.45
PCO2 33-45 mmHg
PO2 75-105 mmHg
Glucose, serum Fasting: 70-110 mg/dL
2-h postprandial:<120 mg/dL
Growth hormone - arginine stimulation Fasting: <5 ng/mL
Provocative stimuli: > 7ng/mL
Immunoglobulins, serum  
IgA 76-390 mg/dL
IgE 0-380 IU/mL
IgG 650-1500 mg/dL
IgM 40-345 mg/dL
Iron 50-170 μg/dL
Lactate dehydrogenase, serum 45-90 U/L
Luteinizing hormone, serum/plasma Male: 6-23 mIU/mL
Female: follicular phase: 5-30 mIU/mL
midcycle: 75-150 mIU/mL
postmenopause 30-200 mIU/mL
Osmolality, serum 275-295 mOsmol/kd H2O
Parathyroid hormone, serume, N-terminal 230-630 pg/mL
Phosphatase (alkaline), serum (p-NPP at 30° C) 20-70 U/L
Phosphorus (inorganic), serum 3.0-4.5 mg/dL
Prolactin, serum (hPRL) < 20 ng/mL
Proteins, serum  
Total (recumbent) 6.0-7.8 g/dL
Albumin 3.5-5.5 g/dL
Globulin 2.3-3.5 g/dL
Thyroid-stimulating hormone, serum or plasma .5-5.0 μU/mL
Thyroidal iodine (123I) uptake 8%-30% of administered dose/24h
Thyroxine (T4), serum 5-12 μg/dL
Triglycerides, serum 35-160 mg/dL
Triiodothyronine (T3), serum (RIA) 115-190 ng/dL
Triiodothyronine (T3) resin uptake 25%-35%
Urea nitrogen, serum 7-18 mg/dL
Uric acid, serum 3.0-8.2 mg/dL
Hematologic Reference Range
Bleeding time 2-7 minutes
Erythrocyte count Male: 4.3-5.9 million/mm3
Female: 3.5-5.5 million mm3
Erythrocyte sedimentation rate (Westergren) Male: 0-15 mm/h
Female: 0-20 mm/h
Hematocrit Male: 41%-53%
Female: 36%-46%
Hemoglobin A1c ≤ 6 %
Hemoglobin, blood Male: 13.5-17.5 g/dL
Female: 12.0-16.0 g/dL
Hemoglobin, plasma 1-4 mg/dL
Leukocyte count and differential  
Leukocyte count 4,500-11,000/mm3
Segmented neutrophils 54%-62%
Bands 3%-5%
Eosinophils 1%-3%
Basophils 0%-0.75%
Lymphocytes 25%-33%
Monocytes 3%-7%
Mean corpuscular hemoglobin 25.4-34.6 pg/cell
Mean corpuscular hemoglobin concentration 31%-36% Hb/cell
Mean corpuscular volume 80-100 μm3
Partial thromboplastin time (activated) 25-40 seconds
Platelet count 150,000-400,000/mm3
Prothrombin time 11-15 seconds
Reticulocyte count 0.5%-1.5% of red cells
Thrombin time < 2 seconds deviation from control
Volume  
Plasma Male: 25-43 mL/kg
Female: 28-45 mL/kg
Red cell Male: 20-36 mL/kg
Female: 19-31 mL/kg
Cerebrospinal Fluid Reference Range
Cell count 0-5/mm3
Chloride 118-132 mEq/L
Gamma globulin 3%-12% total proteins
Glucose 40-70 mg/dL
Pressure 70-180 mm H2O
Proteins, total < 40 mg/dL
Sweat Reference Range
Chloride 0-35 mmol/L
Urine  
Calcium 100-300 mg/24 h
Chloride Varies with intake
Creatinine clearance Male: 97-137 mL/min
Female: 88-128 mL/min
Estriol, total (in pregnancy)  
30 wks 6-18 mg/24 h
35 wks 9-28 mg/24 h
40 wks 13-42 mg/24 h
17-Hydroxycorticosteroids Male: 3.0-10.0 mg/24 h
Female: 2.0-8.0 mg/24 h
17-Ketosteroids, total Male: 8-20 mg/24 h
Female: 6-15 mg/24 h
Osmolality 50-1400 mOsmol/kg H2O
Oxalate 8-40 μg/mL
Potassium Varies with diet
Proteins, total < 150 mg/24 h
Sodium Varies with diet
Uric acid Varies with diet
Body Mass Index (BMI) Adult: 19-25 kg/m2
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(OMB11.1) An 86-year-old man is admitted to the hospital for management of pneumonia. His hospital course has been relatively uneventful, and he is progressing well. On morning rounds nearing the end of the patient's hospital stay, the patient's cousin finally arrives to the hospital for the first time after not being present for most of the patient's hospitalization. He asks about the patient's prognosis and potential future discharge date as he is the primary caretaker of the patient and needs to plan for his arrival home. The patient is doing well and can likely be discharged in the next few days. Which of the following is the most appropriate course of action? Review Topic

QID: 210457
1

Bring the cousin to the room and ask the patient if it is acceptable to disclose his course

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2

Bring the cousin to the room and explain the plan to both the patient and cousin

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3

Explain that you cannot discuss the patient's care at this time

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4

Explain the plan to discharge the patient in the next few days

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5

Tell the cousin that you do not know the patient's course well

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