The correct answer is E. 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 to the treatment. Note that life support will not be maintained indefinitely. Should the 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 was not already obtained and there was no clear statement of the patient's 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 (and should have) discussed end-of-life care issues with this patient, and may provide a window into the unconscious patient's true wishes. In this case, because other information is available, the consultation with the primary care physician will yield nothing new.
The issue here is not the wife's wishes (choice F) but the patient's consent to mechanical support as a part of postoperative recovery. Remember that spouses are relevant only insofar as they represent the wishes of their partners. The medical team acts, not on her wishes, but only on his.
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, in his living will, asked to avoid. Life support should not be indefinite (choice G), but should be terminated when the prognosis changes for the worse.
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.
This is a single-step non-diagnosis question.
What is the question asking?
You are asked to determine the most appropriate next step in patient care.
What relevant information is provided in the vignette?
A 68-year-old male consents to a lung transplant for which mechanical ventilation is standard postoperative care. The physician is uncertain how long the patient will require mechanical ventilation, but there is no information provided in the vignette about the patient having an unfavorable prognosis. The patient?s son presents a living will signed by the patient stating that he wishes not to be kept alive by mechanical means. The patient's wife does not want the ventilator removed.
What is the underlying concept that will help answer this question?
- Providing informed consent for a surgery includes consenting to the surgery as well as standard postoperative care.
- Living wills dictate what a patient wants and does not want during end-of-life care.
- A patient?s own decision will supersede any advanced directed.
- A living will supersedes a medical power of attorney or other surrogate decision-maker in an end-of-life situation.
Can other answers be eliminated?
- There is enough information provided in the vignette to determine the best course of action. Any answer that suggests seeking outside opinions from a court (choice A) or an ethics committee (choice B) can be eliminated.
- The patient has consented to the surgery and standard postoperative care. Any answer choice overrules the patient?s own informed decision, either through the use of family (choice C), the patient?s primary care physician (choice D), or the wife (choice F), can be eliminated.
- Any answer that suggests a living will should be implemented in a situation that is not end-of-life (choice H) can be eliminated.
- The patient does have a living will that states he does not want to be kept alive by mechanical means. Therefore, any answer that suggests that he would be kept alive indefinitely (choice G) can be eliminated.
What is the single best answer and why?
Maintain 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 (choice E) is the single best answer because mechanical ventilation should be continued as it is part of standard postoperative care. Once the patient?s chance of recovery becomes unlikely, his living will would be implemented, and he would be removed from mechanical ventilation per his directive.
MedEssentials (4th Ed.): pp. 32, 33
First Aid (2019): pp. 265.2
First Aid (2018): pp. 261.2
First Aid (2017): pp. 255.1
