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NBME 21 Answers

nbme21/Block 4/Question#48

A 75-year-old man with dementia, Alzheimer type, is ...

Encourage the family to come to a consensus based on their perception of the patient's wishes

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 +7  upvote downvote
submitted by sbryant6(68),

This question is two-fold. You must know the decision-making hierarchy and also consider autonomy. Making "recommendations" for certain treatments is wrong, because it violates autonomy and informed consent. Physicians should simply explain the RBA's of all treatment options, and allow the family to decide what is best based on informed consent and "their perceptions of the PATIENT'S wishes". If there is no advanced directive, then the decision should be appealed to a surrogate decision-maker. Priority of surrogates is spouse-->adult children-->parents-->siblings. Yes, the spouse would have higher priority, but the family should at least try to reach a consensus first before appealing to "only" the wife. If a consensus, cannot be made, then the wife would have first say in the decision. Therefore, encouraging the family to decide according to the wishes of the PATIENT would be a better first step, especially if the wishes of the wife is contrary to that of the patient. Also, just as a general rule, I typically avoid picking answer options with "absolutes" such as "never, always, only". The purpose of a surrogate is to act in the best interest of the patient.

sbryant6  Correction. According to UWorld Social Sciences (Ethics/Legal/Professional): Advance Directives... "situations in which family members disagree and there is no proxy can be referred to the ethics committee or, as a last resort, to the courts". +1  

I get that this answer choice is the most amicable answer.

But honestly the way they asked the question "it is most appropriate for the physician to address the issue of a feeding tube in which of the following manners"

My reasoning was: well...before the family can even begin to argue what do do don't you have to propose a medical treatment/management strategy? which is why I went with "recommend a tube..."

home_run_ball  Like what is the learning objective of this question? On first aid if you go by the Surrogate decision maker priority: you do spouse first...so like wtf nbme? +9  
uslme123  I think it's because there isn't a legally appointed health care surrogate in this case. The family hierarchy is only an "ethical suggestion." +1  
nala_ula  According to first aid, there is an order to who makes decisions when the patient is not able to and hasn't left any directives. My issue was the same as home_run_ball, since they specifically asked about the feeding tube and not "who is supposed to make decisions now" even though that is also warped since the spouse has precedence. +1  

 +1  upvote downvote
submitted by sahusema(73),

What a GARBAGE question. He was eating breakfast 2 hours ago just fine and now we are supposed to have the family come to a consensus about a feeding tube like he's on his death bed? BULLSHIT

 +0  upvote downvote
submitted by imgdoc(72),

I think the answer was consensus because the "surrogates" aka family members havent deliberated yet. If this was after their deliberation and they disagree, then it goes spouse -> adult children -> parents -> siblings etc. The question doesn't mention any disagreements, hence they need to decide cumulatively and make a decision.

That was just my take on this question.

This is a bullshit question. According to everything we've ever been taught the decision goes to the wife if there's no documentation.

 +0  upvote downvote
submitted by temmy(77),
i think the questions is trying to show the importance of unity among family members when there is a patient who is loved by both wife and kids. The duty of the doctor is to ensure the family is united in support of the patient the and in case there is still conflict regarding what to do, you use the hierarchy where wife comes first. i get it was a dumb but this was my logic