Challenging clinical and

ethical scenarios
(Challenging patient scenarios)
Last edited: Jul 11, 2023

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Summary
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.”

NOTES
FEEDBACK

Patient-physician relationships
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.

NOTES
FEEDBACK

Autonomy, informed consent, and decision making

capacity
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.

NOTES
FEEDBACK

Pediatric decision making

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.

NOTES
FEEDBACK

Medical records, reporting, intimate partner violence,

and older adult abuse
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).

NOTES
FEEDBACK

Disclosure, privacy, confidentiality, and medical

errors
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.

NOTES
FEEDBACK

Physicians and community health

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.
NOTES
FEEDBACK

Professional self-regulation
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.

NOTES
FEEDBACK

Caring for patients at the end of life

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.

NOTES
FEEDBACK

Physician-patient counseling
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.