If you’re preparing for the United States Medical Licensing Examination® (USMLE®) Step 3 exam, you might want to know which questions are most often missed by test-prep takers. Check out this example from Kaplan Medical, and read an expert explanation of the answer. Also check out all posts in this series.
This month’s stumper
A 102-year-old widower is brought to the clinic from his apartment by a neighbor because of a cough productive of green sputum. He had a stroke 10 years ago and has residual left arm weakness. He takes no medications. Vital signs are temperature 38.8º C (101.8º F), blood pressure 100/50 mm Hg, pulse 110 beats per minute.
On physical examination rhonchi are found in the right lower lung field. Chest x-ray reveals an infiltrate in the right lower and middle lobes. The patient has a score of 30/30 on a Mini Mental Status exam. The patient says, "I've lived a good life and I don't want to end up in the hospital."
He refuses any IV medications and will take only pills. After you discuss with him the fact that the pneumonia could potentially be fatal without IV antibiotic treatment, he continues to ask to be sent home. The neighbor insists that the patient should be admitted to the hospital.
Which of the following is the best next step in management?
A. Admit the patient to hospital care with intravenous antibiotics.
B. Refer the patient to assisted living or hospice.
C. Admit the patient to the psychiatric ward on grounds of incompetence.
D. Discharge the patient home with oral antibiotics.
E. Discuss the case with the hospital attorney.
F. Initiate antidepressant therapy and administer intravenous antibiotics.
The correct answer is D.
Kaplan Medical explains why
The principle of patient autonomy allows patients to make their own decisions regarding their medical management. The only exceptions are if the patient has no clearly expressed wishes documented, is unable to make a decision, or is deemed incompetent.
This patient clearly has the capacity to refuse treatment, despite the wishes of his physician or neighbor. It is important to make the consequences of his decision clear to the patient before discharge, and to tell him that he should return immediately if he changes his mind.
Why the other answers are wrong
Choice A: Hospital care with or without IV antibiotics is inappropriate because this patient is refusing hospital care.
Choices B, C and E: This patient has the capacity to refuse treatment, so he should not be referred to assisted living or hospice. Neither should he be admitted to the psychiatric ward no given antidepressant therapy.
Choice F: The patient’s decision should be respected and he should be discharged home with appropriate treatment—in this case, antibiotics. Consultation with an attorney is not necessary. This patient clearly has the capacity to refuse medical care.
Tips to remember
- Patient autonomy allows patients to have the final decision in their management.
- Autonomy has priority over beneficence.
For more prep questions on USMLE Steps 1, 2 and 3, view other posts in this series.
The AMA and Kaplan have teamed up to support you in reaching your goal of passing the USMLE® or COMLEX-USA®. If you're looking for additional resources, Kaplan provides free access to tools for pre-clinical studies, including Kaplan’s Lecture Notes series, Integrated Vignettes, Shelf Prep and more.
