Challenging clinical and ethical scenarios

This article focuses on challenging clinical scenarios that involve the correct application of professional ethical principles. Questions about medical ethics have become increasingly common in the USMLE, and this article provides a practical overview, giving step-by-step approaches to several complex situations or problems in everyday clinical practice. This article is meant for rapid review prior to taking the exams and complements our Qbank, which contains questions on many similar scenarios.

For more in-depth information on the concepts discussed in this article, see: "Principles of medical law and ethics," “Patient communication and counseling," "Health care system," "Approach to the agitated or violent patient," "Sexual violence,” “Intimate partner violence,” “Older adult abuse," and “Death.”

Romantic or sexual relationships with patients and key third parties ^[1]

• Scenario 1: A patient's mother expresses romantic interest in you and invites you to lunch.
• Approach
  • Never enter a romantic relationship with a current patient or key third parties (i.e., those involved in patient decision-making and care).
  • Set firm boundaries and avoid unnecessary contact.
    • Ask specific, close-ended questions.
    • Use a chaperone if necessary.
    • Consider transitioning care to another physician.
• Scenario 2: A patient makes a sexually inappropriate comment during genital examination.
• Approach
  • Inform the patient politely and directly that their comment is inappropriate.
  • Request the presence of a chaperone.
  • Ask only direct, close-ended questions.
  • Perform only medically necessary portions of the examination to minimize contact.

Romantic relationships with patients or key third parties are always considered unethical and inappropriate.

Self-treatment, treatment of relatives and friends ^[2]

• Scenario 1: A close friend asks you to prescribe oral contraceptives before going on vacation because she forgot to ask her physician for a refill.
• Approach
  • Avoid providing treatment or prescribing drugs to yourself, your immediate relatives, or your friends.
  • Exceptions include:
    • In emergencies and/or in isolated settings where no other qualified physicians are available
    • Minor events (e.g., a bloody nose, first-degree burns)
• Scenario 2: Your father has been in a motor vehicle collision and requires an urgent surgical procedure. He requests that you perform the procedure because you work at the same hospital and he trusts in you.
• Approach: Seek permission from the primary attending surgeon to be the assistant surgeon in the procedure.

Accepting gifts from patients ^[3]

• Scenario 1: A patient has offered you an origami swan and a thank you card.
• Approach: Thank the patient and accept the gifts since they do not have a substantial monetary value.
• Scenario 2: A patient offers your office a framed painting by a well-known artist from his private art collection.
• Approach
  • Show appreciation while politely declining the gift.
  • Explain the reasoning (i.e., to avoid potential conflicts of interest, physicians must decline gifts that are intimate and/or highly valuable).
  • Assure the patient that declining the gift does not affect the physician-patient relationship.
• Scenario 3: A patient with an active mood disorder offers you a $100 gift card for a spa.
• Approach
  • Do not accept gifts from patients experiencing a mood episode that potentially affects their judgment.
  • Assure the patient that declining the gift does not affect the physician-patient relationship.

Accepting gifts from the industry ^[4]

• Scenario 1: You publish an important paper about a new medication that would directly benefit your patients. The pharmaceutical company offers to sponsor your travel and lodging costs for the conference as well as funding to develop the drug at the hospital where you work.
• Approach
  • Reject both the offer for the trial funding and the conference sponsorship.
  • Industry-sponsored research is only permissible if there are no conflicts of interest, the institutional review board gives permission, and all sources of funding are duly disclosed.
• Scenario 2: A pharmaceutical company offers educational material on healthy diets for patients with hypertension.
• Approach: Accept the gift from the pharmaceutical company because it directly benefits patients and the value is not substantial.

Autonomy

• Scenario 1: An adult patient refuses treatment because of their religious beliefs.
• Approach
  • Explain all of the available treatment options.
  • Confirm that the patient understands the consequences of their decision.
  • Respect the patient's choice.
• Scenario 2: An unconscious adult who was in a car accident has already received fluids and has severe bleeding, requiring transfusion before emergency surgery. The accompanying friend claims the patient is a Jehovah's Witness but has no documentation to prove it and the family members cannot be contacted.
• Approach
  • Provide lifesaving treatment to the patient by ensuring transfusion.
  • This patient's preferences are not clearly documented and there is no suitable surrogate decision-maker present; it is inappropriate to withhold lifesaving treatment based on unverifiable claims.
• Scenario 3: A patient wants to try alternative medicine instead of their prescribed medication for hypercholesterolemia.
• Approach
  • Identify the underlying reason.
  • Do not negate or devalue the patient's decision.
  • Evaluate for possible drug interactions, adverse effects, and overall safety.
  • Allow treatment integration if it poses no risk to the patient.

Informed consent ^[5][6]

• Scenario 1: A patient's spouse or family member wants information about the patient's disease course.
• Approach: Explain that information regarding a patient's health cannot be shared with anyone outside of their direct health care team without the patient's explicit verbal or written consent.
• Scenario 2: An attending physician will perform an urgent procedure and asks you (a PGY-1) to obtain the patient's informed consent.
• Approach: Respectfully explain that informed consent should be obtained by the health care provider performing the intervention.
• Scenario 3: During surgery, you make an incidental finding of another condition that is not life-threatening. There is no durable medical power of attorney.
• Approach
  • Finish the original procedure as planned.
  • A patient's consent is legally required for any nonemergency procedure.
  • Obtain consent for a second operation once the patient is awake and responsive.
• Scenario 4: During surgery, you make an incidental finding of a life-threatening condition.
• Approach
  • Perform the surgery.
  • The requirement for informed consent is waived if the patient faces immediate harm.
• Scenario 5: A patient comes for a routine health check and says that he would like to undergo vasectomy. His wife is also your patient, and during her last visit, she said that she would like to conceive soon.
• Approach
  • Explore the patient's reasons for undergoing vasectomy.
  • Explain the procedure's risks, benefits, and potential alternatives.
  • Although the wife's consent is not required to perform the procedure, encourage the patient to discuss his decision with her.

Shared decision-making

• Scenario 1: A patient requests a nonemergency treatment or procedure that conflicts with your personal or religious beliefs.
• Approach
  • Impartially inform the patient about all of the options, in order to help them make an informed decision.
  • Respectfully explain that you will not perform the requested intervention because of your personal beliefs, and transition care to another qualified physician.
• Scenario 2: A patient requests an unnecessary intervention (e.g., diagnostic or therapeutic procedure, medication).
• Approach
  • Ask why the patient wants the intervention and address any underlying concerns.
  • Do not perform unnecessary medical or surgical interventions.
  • Do not refuse to see the patient or refer the patient to another physician.
• Scenario 3: : A patient refuses the initially prescribed medication and asks about a different drug.
• Approach
  • Initiate an open-ended conversation and explore the patient's understanding of his illness, knowledge about each medication, and the thought process underlying his preferences.
  • Address any misconceptions that are raised in the conversation.
  • Discuss the advantages and disadvantages of each regimen.

Futile treatment ^[7][8][9]

• Scenario 1: A patient is brought into the emergency department after a major trauma (e.g., fall from a building). CPR was provided by emergency medical technicians for 10 minutes. On arrival, the patient remains in cardiac arrest, and all reversible causes of posttraumatic cardiac arrest have been excluded while continuing CPR but without any rhythm change or return of spontaneous circulation. After 20 minutes, you have pronounced death. The patient's wife arrives at the ED and asks the physicians to continue CPR.
• Approach
  • Carefully notify the spouse about her husband's death and explain that all resuscitative efforts were performed (e.g., effective CPR for > 30 minutes without ROSC, no shockable rhythm).
  • Physicians are not required to provide further treatment when there is no prospect of recovery.
• Scenario 2: A patient's family insists on maintaining life support indefinitely despite evidence of brain death because the patient still moves when touched.
• Approach
  • Carefully explain to the family that brain death is equivalent to death and excludes any chance of recovery.
  • Clarify that the movements are only an involuntary result of the spinal arc reflex.
  • If the family insists, contact the appropriate medical ethics committee that decides on cases of futile treatment and the withdrawal of life-sustaining treatment.

Decisions for adult patients who lack decision-making capacity

• Scenario 1: A patient has an advance health care directive declining cardiopulmonary resuscitation and verbally confirmed these wishes to you and your attending on admission. He is now in cardiac arrest and his spouse insists that you perform lifesaving measures.
• Approach
  • Carefully explain that you are legally obligated to honor the patient's wishes regarding end-of-life care.
  • An advance directive should only be disregarded if it conflicts with the patient's most recently expressed wishes.
• Scenario 2: A patient is acutely intoxicated from consuming a large amount of alcohol. He refuses treatment, demands to be discharged immediately, and threatens to call his lawyer to sue the entire medical staff.
• Approach
  • Determine the patient's decision-making capacity (this patient's capacity is impaired).
  • Explain to the patient that discharge would seriously endanger his health.
  • Admit the patient.
  • Reassess the patient's decision once he is no longer impaired.
• Scenario 3: An unconscious patient with multiple comorbidities is brought to the ER by his neighbor. On examination, the patient is unresponsive. The neighbor says that the patient has long insisted that he would refuse dialysis or any other life-prolonging measures. His only living relative is his estranged father.
• Approach
  • The patient lacks decision-making capacity, and there is no written advance directive to guide treatment. Therefore, a surrogate decision-maker is required to act on the patient's behalf.
  • Try to contact the next of kin (the father) for consent.
  • If the father cannot be reached, the patient's neighbor might act as a surrogate decision-maker.
• Scenario 4: A 91-year-old patient is unable to communicate or safely swallow food. Her sister requests placement of a percutaneous endoscopic gastrotomy tube for nutrition. However, the patient's husband declines the intervention, and there is no advance directive.
• Approach
  • Encourage a family meeting between the patient's husband, sister, and members of the health care team to discuss the patient's likely wishes.
  • If the disagreement cannot be resolved, the patient's next of kin (her husband) decides.
• Scenario 5: A patient with schizophrenia and advanced metastatic lung cancer comes for a follow-up evaluation. You recommend palliative percutaneous gastrostomy and explain the procedure, including its risks and benefits. The patient objects to the proposed treatment, refuses lifesaving measures, and designates his brother as medical power of attorney. Weeks later, on a follow-up appointment, the patient is alert and oriented with mild impaired cognition and continuing features of schizophrenia. He says that he has changed his mind and wants to undergo the procedure. His brother is present during the consultation and strongly disagrees with the patient's decision.
• Approach
  • Reassess the patient's decision-making capacity.
    • Ask the patient to explain their understanding of their condition and the procedure.
    • Actively listen to the patient's wishes.
    • Evaluate the patient's capacity and legal competence (e.g., with a MacArthur Competence Assessment Tool).
• Scenario 6: A patient with terminal ovarian cancer has declined additional procedures and provided an advance directive designating a medical power of attorney to her eldest daughter. On physical examination, the patient is alert and cooperative. She says that she does not want to receive any lifesaving procedures and understands the consequences of her decision. However, the patient's daughter objects and says that her mother should receive all the necessary measures to stay alive.
• Approach
  • Follow the patient's verbally expressed wishes.
  • Do not take any lifesaving measures.
• Scenario 7: A patient who was declared brain dead is placed on life support and has no advance directive regarding organ donation. You discuss organ donation with the patient's family (her 17-year-old son, eldest brother, and parents). The patient's brother agrees with organ donation, whereas her parents strongly disagree, and the son cannot be reached. The family cannot reach an agreement.
• Approach
  • Do not proceed with organ donation.
  • Most states grant decision-making authority to the next of kin.
  • If the patient lacks decision-making capacity or is deceased and does not have an advance directive or a self- or court-appointed surrogate decision-maker, the next of kin (the parents) become the surrogate decision-makers.

Pediatric decision making

Informed consent in minors ^[10]

• Scenario: A 16-year-old boy is brought to you by his parents. They say that he has been “suspiciously withdrawn” lately and has also lost some weight. Physical and mental status examinations show no abnormalities. At the end of the visit, the patient's mother privately asks you to run a drug test on him under the guise of a routine laboratory test.
• Approach
  • Explain that you cannot lie to the patient.
  • Acknowledge the mother's concerns and investigate the underlying reasons for her request (ask open-ended questions).
  • Explain that a positive urine drug test cannot show a pattern of drug use or whether the patient has a substance use disorder.
  • Talk to the patient alone and share information about the parents' concerns with the minor.
  • If a drug screening test seems appropriate, seek the patient's consent.
  • If the patient agrees to the test, make a plan for disclosure of the results to the parents and the patient before performing the test.
  • Do not perform drug testing without the patient's consent unless they have impaired mental status and/or a history of violent behavior or overdose.

Parental decision to withhold treatment ^[11][12]

• Scenario 1: A father and 13-year-old son are found unconscious with internal bleeding after a car accident. The father has a religious preferences card stating that he declines blood transfusions for himself and his son.
• Approach
  • Ensure transfusion for the son but not for the father.
  • A parent cannot refuse an emergency lifesaving intervention for a minor for any reason (e.g., religious refusal).
  • An adult can refuse lifesaving emergency treatment either with an advance health care directive or explicit verbal consent.
• Scenario 2: An infant is diagnosed with an intermediate-risk neuroblastoma that will result in death if untreated. The parents refuse treatment and prefer to provide supportive care only.
• Approach
  • Explain that the patient has a potentially life-threatening condition that requires timely treatment.
  • If the parents refuse intervention, seek a court order to mandate treatment.
• Scenario 3: A newborn is diagnosed with kernicterus and requires exchange transfusion and phototherapy. The parents refuse treatment and request immediate discharge.
• Approach
  • Explain that the patient has a life-threatening condition that requires immediate intervention.
  • Admit the patient and administer treatment.

Treatment decisions in emergency situations ^[11]

• Scenario: A 4-year-old boy needs an urgent intervention, but the parents cannot be reached.
• Approach
  • Perform emergency surgery.
  • Parental consent is required before a minor receives medical care, but there are exceptions, such as emergency and/or life-saving interventions.

Confidential health care for minors

• Scenario 1: A 14-year-old girl requests contraceptives.
• Approach
  • Offer advice on safer sex practices and discuss all effective contraceptive options.
  • Prescribe contraceptives and encourage the patient to communicate her choice to her parents.
• Scenario 2: A 15-year-old girl is pregnant and wants to carry the baby to term, but her parents disagree.
• Approach
  • Pregnant individuals of any age have the right to choose whether to carry their pregnancy to term and whether to opt for adoption after birth.
  • Provide practical information about all options.
  • Support the patient's decision and encourage good communication with her parents to promote shared decision-making.
• Scenario 3: An unemancipated minor has an STI and seeks treatment. He does not want to disclose his health status to his parents.
• Approach
  • Prescribe and/or initiate STI treatment (parental consent is not required).
  • Report the case to a public health official if the patient has a reportable disease (e.g., Neisseria gonorrhea, Chlamydia trachomatis infection).
  • Encourage the patient to inform all of his sexual contacts within the past 60 days.
  • If the patient refuses to inform their sexual contacts, use the confidential partner notification procedures via the health department.
• Scenario 4: A 15-year-old patient is brought by their mother for a well-child examination. The mother complains about the patient's health and habits and wants you to scold them.
• Approach
  • Address the parent's concerns and politely ask them to leave the examination room.
  • Explore and discuss the patient's feelings.
  • Be empathetic and acknowledge the patient's need for privacy and growing independence.
  • Provide sufficient information for the patient to make their own decisions regarding their care.
• Scenario 5: A 14-year-old is brought by their mother for a well-child examination. The mother asks the daughter about her sexual activities during the consult, but the teenager does not respond.
• Approach
  • Kindly ask the mother to step out so that you can speak privately with the patient.
  • If the mother refuses to leave, offer to have an additional member of the staff (e.g., a nurse) present during the examination.
  • If she still refuses, respect her decision and document that the patient's sexual history was not discussed because of her mother's presence during the visit.

• Scenario 6: Parents refuse to vaccinate their child during a well-child visit.
• Approach
  • Respect the parents' decision and address their concerns regarding vaccination.
  • Provide the parents with reliable information regarding the risks and benefits of vaccination and address any misconceptions to ensure an informed decision.
  • Document the parents' refusal to vaccinate.
  • Revisit the topic in subsequent visits.

Do not administer vaccines without parental consent.

Parental decision to choose alternative treatments for children ^[13]

• Scenario: A 6-year-old child is brought by his mother because of a high fever and sore throat. Examination reveals streptococcal pharyngitis for which you prescribe antibiotics. The mother refuses the medication and insists that she will treat the child with apple cider vinegar and ginger beverages.
• Approach
  • Practice nonjudgmental collaboration: build rapport and trust with parents to maintain the therapeutic relationship.
  • Parents have the right to choose complementary and alternative medicine interventions for their children if they do not pose a high risk of harm.
  • Explain why antibiotics are recommended and the risks posed to the child if they are not used.
  • Schedule a follow-up visit.

Suspicion of child abuse ^[14]

• Scenario: A 6-year-old patient has an injury that is inconsistent with the explanation given by their parent.
• Approach
  • Interview the child separately and document a detailed history and physical examination with a chaperone present.
  • Provide any necessary medical care.
  • If the parent is suspected of abuse, the patient should be admitted for their safety.
  • If suspicion of child abuse remains, notify Child Protective Services.

Emancipated minors

• Scenario: : A 17-year-old boy who lives alone, supports himself financially without assistance, and has not had any contact with his parents in over a year is diagnosed with a lipoma and is seeking medical treatment.
• Approach
  • Offer surgical treatment.
  • Emancipated minors can consent to their own medical care.

Medical records ^[15]

• Scenario: A patient who works in hospital management comes to the ER with an “embarrassing” condition and asks you to alter their patient records because they are ashamed that someone else will read about it.
• Approach
  • Reject the patient's request. Falsification of records is unethical.
  • Reassure the patient that his records are treated confidentially.

Reporting ^[16]

• Scenario: A 74-year-old patient with Parkinson disease comes in for a routine exam and says that he still uses his car to run errands and go to his medical appointments.
• Approach
  • Laws for reporting impaired drivers vary among states.
  • Physicians may be required to report patients who are considered unsafe to drive to the licensing authority (e.g., Department of Motor Vehicles).
  • Before reporting, share your concerns with the patient, and encourage further evaluation and treatment (e.g., occupational therapy, substance rehabilitation).
  • If you are planning to make a report, inform the patient.

Intimate partner violence ^[17]

• Scenario: A patient discloses abuse by their spouse.
• Approach
  • Evaluate the patient's safety and offer to help develop an emergency plan.
  • Show empathy and willingness to provide continuous support.
  • Evaluate for psychological comorbidities and refer for counseling if necessary.
  • Thoroughly document evidence of abuse for legal purposes.
  • Do not counsel the patient to leave their partner.
  • Do not disclose suspected abuse to the authorities (unless required by state law).

Older adult abuse ^{[18][19][20][21]}

• Scenario: An incapacitated 82-year-old patient is admitted with clinical features that cannot be explained by his medical history.
• Approach
  • Thoroughly document any warning signs and common features of abuse (e.g., unexplained soft tissue injury, dehydration, malnourishment, changes in behavior).
  • Notify the appropriate authorities (e.g., Adult Protective Services, Long-Term Care Ombudsman programs).

Disclosure

Withholding information from patients

• Scenario 1: Family members request that you withhold a lung cancer diagnosis from the patient.
• Approach
  • Explore why the family members want to withhold the information, and explain that the diagnosis will be disclosed to the patient unless the patient declines.
  • Determine how much information the patient wants to receive about their diagnosis and prognosis.
  • Disclose the information to the patient based on their preferences.
  • According to therapeutic privilege, the physician may withhold certain information (e.g., diagnosis) from the patient if disclosure increases the likelihood of self-harm.
• Scenario 2: The patient requests that the physician withhold diagnostic test results from him. Upon repeat questioning, the patient reaffirms his wish to not know the diagnosis.
• Approach
  • Patients have the right to decline knowledge or discussion of their diagnoses.
  • Explore why the patient has declined to learn about their test results and/or diagnosis.
  • If the patient continues to decline knowledge, ask them to choose a family member to whom the diagnosis can be disclosed.

Information disclosure by medical students ^[22]

• Scenario: : A patient asks you (a medical student) to disclose treatment, diagnostic, or prognostic information.
• Approach
  • Be honest and tell the patient that you cannot disclose any treatment, diagnostic, or prognostic information.
  • Tell the patient that the information will be disclosed by senior members of the health care team.

Disclosing information on the patient's health condition to family members

• Scenario: : A family member requests information about the patient's health condition, but the patient does not want you to disclose the information.
• Approach: Explain to the family member that you cannot discuss medical information with anyone without the patient's permission.

Disclosing information on the patient's health condition to health insurance companies ^[23][24]

• Scenario: A patient's health insurance company asks how long you think the patient will remain hospitalized.
• Approach: Only provide the requested information and nothing beyond that (i.e., in this scenario, estimated duration of hospital stay).

Disclosing information on notifiable diseases ^[25]

• Scenario: : A patient with a new HIV diagnosis refuses to inform their partner.
• Approach
  • Report the case to the public health authorities because HIV is a reportable disease.
  • Encourage the patient to disclose the information to their sexual partner.
  • If the patient refuses to inform their partner, use the health department's confidential partner notification procedures.

Disclosing medical errors ^[26][27][28]

• Scenario 1: A physician colleague made an error in patient management that might have serious consequences.
• Approach
  • Privately speak to the colleague who made the error and attempt to find out why it occurred.
  • Inform the patient about the error, discuss its implications, and ensure continuity of care.
  • Advocate for systemic changes to reduce the risk of future medical errors.
• Scenario 2: A patient receives the wrong treatment or test.
• Approach
  • Inform the patient (even if no harm has been inflicted).
  • Apologize to the patient.
  • Express personal regret and/or apologize to the patient.

Patient discloses suicidal or homicidal ideation or plans ^[5]

• Scenario 1: A patient has suicidal ideation or plans.
• Approach
  • Assess the threat (e.g., the presence of an organized plan or access to weapons).
  • Discuss voluntary admission to a psychiatric unit with the patient.
  • If the patient refuses, admit involuntarily.
• Scenario 2: A patient with a suspected psychiatric disorder says during the examination that he plans to kill someone with his gun.
• Approach
  • Evaluate the situation, including the identity of the intended victim, the type of harm (e.g., violence, death), and the imminence and certainty of the threat.
  • Assess the patient for psychiatric disorders (e.g., schizophrenia).
  • If there is a risk of serious and imminent harm to a third party based on the information provided by the patient, break confidentiality, and inform law enforcement authorities and the person at risk.

Research disclosure ^[29]

• Scenario: A patient with a rare type of cancer and a poor prognosis participates in a clinical trial using a new surgical technique. The patient consents to participate after full disclosure. After the surgery was performed and during a follow-up stage of the trial, he says that he no longer wishes to participate in the study.
• Approach
  • Acknowledge the patient's right to withdraw from the clinical trial.
  • Inquire about the reason for withdrawal to identify any potential risks or adverse events.
  • Clarify whether the participant wants to withdraw completely (i.e., from all aspects of the study including follow-up) or only partially.
    • Informed consent on partial participation should be obtained.
    • In the event of complete withdrawal, the participant should not be contacted for further study-related activities, and no additional information should be collected about them. The information collected to date may be kept.

Substitution of a doctor

• Scenario: A patient complains about the treatment received from another physician.
• Approach
  • Encourage the patient to contact the physician directly about their concerns.
  • If the complaint is about a member of your staff, tell the patient that you will address the issue with your colleague personally.

Disparities in healthcare ^[30]

• Scenario: A patient is brought to the emergency department with features that suggest acute myocardial infarction, and they have no health insurance.
• Approach
  • According to the Emergency Medical Treatment and Labor Act (EMTALA), emergency departments are required to evaluate, treat, and stabilize patients presenting with emergency medical conditions (including labor) without regard for the patient's ability to pay for the treatment provided.
  • Initiate medical screening examination and treatment.
  • Explain to the patient that if you determine that there is no medical emergency, they are financially liable for any further treatment.

Health promotion and preventive care

• Scenario: A patient does not follow the medical plan or has difficulty taking medications.
• Approach
  • Talk with the patient in a nonjudgmental manner and identify the potential barriers to adherence (e.g., financial, logistical, informational).
  • Optimize and adapt the treatment regimen to the patient's needs (e.g., change the dose or formulation, switch to a less costly regimen).
  • Describe the treatment plan in accessible language, give written instructions, use the teach-back method, and involve close friends and relatives (with the permission of the patient).
  • Consider integrating interventions into the patient's schedule (e.g., automated reminders).
  • Schedule regular follow-up visits.
  • Do not refer the patient to another physician.

Medical students and fellow physicians’ involvement in patient care

Medical student participation in patient care ^[31]

• Scenario: A medical student doing a clerkship on a surgical ward is interested in participating in a patient's surgery.
• Approach: Disclose the student’s identity and training status to the patient and ask for consent.

Information disclosure to fellow physicians

• Scenario: A physician colleague not directly involved in care wants to know the medical status of a friend who you treat.
• Approach
  • Express empathy with your colleague.
  • Inform them that because of the patient's right to privacy, you are unable to provide the information.
  • The patient may give their consent to disclose information to their friend but only with prior agreement.

Peer review & disciplinary action ^[32][33][34]

• Scenario 1: A physician colleague is impaired in the work environment (e.g., due to substance use).
• Approach: Report the physician to a hospital or physician health program.
• Scenario 2: : A physician colleague discloses that he sometimes leaves the hospital during working hours to run personal errands.
• Approach
  • Report the physician to the hospital authorities (e.g., department chair, chief medical officer, peer review body).
  • If the behavior poses a threat to patient health, contact the state licensing board.
• Scenario 3: You discover that a colleague is routinely referring his Medicare and Medicaid patients for unnecessary physiotherapy sessions to increase the profits of his rehabilitation facility.
• Approach
  • Contact the state medical licensing board.
  • Inform the CMS office in all cases of suspected Medicaid and Medicare billing fraud.

Performing procedures on a newly deceased patient ^[35]

• Scenario: A patient is pronounced brain dead. The emergency medicine resident, who assisted in this patient's resuscitative efforts, asks the attending physician if he can practice catheterization on the patient. There are no advance directives or emergency medical contacts in the patient's electronic health record.
• Approach
  • Attempt to contact the patient's family.
  • Consent from the next of kin is required for each procedure if the deceased's preferences are not known.
    • It is unethical to use the body of a deceased patient for training purposes without consent regardless of the degree of invasiveness of the procedure.
    • If consent is obtained, the training should be conducted under close supervision and in a manner that ensures respect for the deceased and their family.

Physician colleague disagreement on patient care

• Scenario: A patient is being treated for a neurodegenerative condition. Her functional status has significantly deteriorated and her prognosis is < 6 months of life remaining. You recommend her for transfer to hospice care, but her neurologist recommends enrollment in a new clinical trial.
• Approach
  • Inform the patient about the risks and benefits of both options.
  • The final decision for any treatment is made by the patient.
  • After the patient has made a decision, coordinate with the neurologist to agree on the next best step.

Physician-assisted dying ^[36]

• Scenario: A patient with a terminal disease asks for assistance in ending their own life.
• Approach
  • Physician-assisted dying is prohibited in most states.
  • Ask the patient to explain their reasons and be empathetic.
  • Discuss and implement palliative care interventions (e.g., pain management).

Pharmacological management in terminally ill patients ^[37][38][39]

• Scenario: A 67-year-old woman, who receives home hospice care for end-stage glioblastoma multiforme, complains of severe pain but is concerned that she already takes too many medications.
• Approach
  • Acknowledge the patient's concern, but tell her that pain management is a priority.
  • Do not discontinue any drugs that might maximize patient comfort (e.g., analgesics, antiemetics, antidepressants, anxiolytics).
  • Consider deprescribing medications that are indicated for primary or secondary prevention and/or have no immediate effect (e.g., antihypertensive, statins, aspirin).

End-of-life care often requires high doses of medication that can cause respiratory depression. Although this practice may hasten the patient's death, it is considered an acceptable compromise according to the principle of double effect. ^[40][41]

Do-not-resuscitate orders (DNR orders) ^[42]

• Scenario: : A 70-year-old woman is admitted for suspected myocardial infarction. The patient has a history of cardiac disease and previously signed a do-not-resuscitate order.
• Approach
  • Explain to the patient that cardiorespiratory arrest is possible and obtain verbal confirmation of her DNR.
  • Document the patient’s clinical status and DNR order.
  • Provide the appropriate medical care.
  • In the event of cardiorespiratory arrest, withhold resuscitative measures.

Physicians intervening in family conflict ^[43]

• Scenario: A patient requests that you intervene in a conflict with one of their family members.
• Approach
  • Avoid triangulation and encourage the patient to voice their concern directly to the family member.
  • If the family member is also your patient, you can:
    • Arrange a family consult (family interview), which provides a structured opportunity for communication.
    • Refer them to a family therapist.
  • In the case of suspected abuse or neglect, the physician should intervene on the patient's behalf.

Offering emotional support to patients ^[44][45]

• Scenario 1: A patient complains that she feels “ugly” after a mastectomy.
• Approach
  • Express empathy and encourage the patient to discuss her feelings.
  • Listen to the patient's concerns and avoid making simplistic comments (e.g., “You look good anyway”) to reassure them.
  • Refer for psychological counseling if appropriate.
• Scenario 2: A 6-year-old child experiences the death of a sibling and feels responsible.
• Approach
  • The understanding that death is final starts to develop at 5–7 years of age.
  • Describe with simple and honest words what happened, avoiding euphemisms and clichés.
  • Offer reassurance, explaining to the child with clear and logical arguments that they are not responsible in any way.
  • Help the child to label feelings and fears, and explain that they are natural.
  • Encourage healthy coping behaviors (e.g., making time for play, creating a special way to remember their sibling).
• Scenario 3: A 32-year-old patient, gravida 2, para 0, at 22 weeks' gestation is brought to the emergency department for abdominal pain and vaginal bleeding. After initial screening, the patient is informed that there are no fetal heart tones and an emergency cesarean delivery should be performed.
• Approach
  • Express empathy and acknowledge the grief that the patient is experiencing.
  • Ensure privacy (e.g., by clearing the room of visitors and nonessential staff).
  • Offer the opportunity to view and hold the baby after delivery.
• Scenario 4: A patient says that she is interested in undergoing female genital circumcision.
• Approach ^[46]
  • Approach the patient in a culturally sensitive and nonjudgmental manner.
  • Explain that the surgery is illegal in the US and you cannot offer it.
  • Explain the risks of the procedure and the risks of undergoing surgery by a practitioner who does not have medical training.
  • Discourage the patient from having the procedure.
  • Refer the patient to social support groups.

Caregiver burnout ^[47]

• Scenario: A patient with dementia is brought by his spouse for a follow-up appointment. While explaining the next steps in management, you notice that the patient's spouse seems detached, irritable, and has a hard time focusing on what you're explaining.
• Approach
  • Ask the spouse how she is coping with the burden of caregiving.
  • Express empathy and acknowledge her experiences.
  • Screen for affective disorders (e.g., depression, anxiety).
  • Suggest coping strategies and behavioral management techniques.
  • Provide information about support services (e.g., caregiver support services, home health services).

Disruptive behavior by patients ^[48]

• Scenario 1: You have just walked into the examination room and the patient is angry because of a long waiting time.
• Approach
  • Apologize to the patient.
  • Acknowledge their anger.
  • Do not try to justify or explain the delay.
  • Immediately address the patient's chief concern.
• Scenario 2: : An excessively needy patient demands your attention for a nonurgent after-hours medical consult.
• Approach
  • Set boundaries by firmly and politely explaining the business hours and how to schedule appointments.
  • Inform the patient about guidelines in place for contacting you outside of office hours.
  • Provide resources for answering routine questions and for seeking help in medical emergencies.
• Scenario 3: A patient with a debilitating chronic condition comes for a follow-up appointment. She says she feels hopeless and disappointed about the efficacy of the treatment.
  • Acknowledge the patient's feelings in an empathetic, nonjudgmental manner.
  • Discuss treatment goals, consider alternative interventions, and manage the patient's expectations.
  • Patients with chronic medical conditions should be monitored for signs of psychiatric disorders (e.g., depression).

Agitated or violent patients ^[49][50][51]

• Scenario 1: An agitated intoxicated patient is brought to the ER by police officers. While you try to perform the physical examination, the patient becomes increasingly aggressive.
• Approach
  • Remove potentially dangerous objects from the patient's reach.
  • Request the presence of additional personnel.
  • Step two arm's lengths away from the patient and position yourself close to the exit.
  • Attempt verbal deescalation.
    • Maintain nonconfrontational body language and demeanor.
    • Respect the patient's personal space.
    • Use concise, simple, and repetitive language.
    • Ask the patient how they are feeling and what they want.
    • Listen actively and reflect that you understand the patient's perceptions and emotions.
    • Seek out points on which you and the patient can agree.
    • Give the patient time to process information and respond.
    • Offer comfort measures (e.g., food, water).
• Scenario 2: An admitted patient becomes severely agitated and aggressive and you are concerned about the potential for violence. You attempt verbal and nonverbal deescalation strategies, but the patient remains uncooperative and combative.
• Approach
  • Administer an intramuscular injection of calming medication based on the suspected cause of agitation (e.g., benzodiazepines for anxiety, antipsychotics for psychosis).
  • Consider physical restraint if calming medication is unsuccessful.
• Scenario 3: An agitated patient comes to the ER and threatens to kill one of the staff unless she is allowed to speak to the attending physician. The patient remains aggressive despite attempts at deescalation and is subsequently physically restrained and sedated.
• Approach
  • Remove restraints after the patient has calmed down or adequate sedation has been achieved.
  • Reevaluate the patient once she is no longer sedated.
    • Determine the cause of agitation and the patient's decision-making capacity.
    • Decide whether the patient should be admitted (e.g., poses a threat to themselves or others) or discharged (e.g., intoxication)

Substance use disorder

• Scenario: : A patient comes for a follow-up appointment 2 weeks after undergoing a successful surgical procedure without complications. He was prescribed oxycodone and acetaminophen. He has a history of recreational drug use. Physical examination shows no abnormalities. However, the patient reports he is in severe pain that prevents him from participating in physical therapy and disrupts his sleep. You recommend switching to ibuprofen for pain, but the patient becomes visibly angry and demands a refill of oxycodone.
• Approach
  • Address the patient in an empathetic, nonjudgmental manner.
  • Inquire about which drugs he has taken recently and in the past to properly assess and treat his pain.
  • Use online federal resources (e.g., prescription drug monitoring programs) to determine if the patient has a history of opioid use disorder or if the patient is actively receiving narcotic prescriptions from multiple physicians.