Legal Issues in Health Care

Alternative Text for Accessibility

Number 1. The basis of all legal and ethical obligations between a physician and a patient.

Correct Answer: Physician-Patient Relationship

Number 2. The physician-patient relationship is the basis of all legal and ethical obligations between a physician and a patient.

Number 3. Two words that describe the physician-patient relationship.

Correct Answer: Mutual and Consensual

Number 4. Mutual and consensual describe the physician-patient relationship.

Number 5. Psychiatrist meets a patient in the grocery store. She has not seen this patient for more than a year. He asks her out to dinner. What should she do?

a. Accept. Dinner with a former patient is harmless.
b. Accept. She hasn't seen this patient for more than a year and the physician-patient relationship has been terminated.
c. Refuse. It may be unethical for a psychiatrist to engage in a romantic relationship with a current or former patient.
d. Refuse because former patients make bad dates.
e. Refuse because ethical considerations require at least a three-year waiting period to date a former patient.

Correct Answer: c. Refuse. It may be unethical for a psychiatrist to engage in a romantic relationship with a current or former patient.

Feedback: It is unethical for any physician to have a romantic relationship with a current patient. It is unethical for a physician to have a sexual or romantic relationship with a former patient if the physician uses or exploits trust, knowledge, emotions, or influence derived from the previous professional relationship. Because psychiatric patients are particularly vulnerable, a psychiatrist may violate ethical guidelines for psychiatrists if he or she has a romantic relationship with a current or former patient.

See generally, AMA Code of Medical Ethics, Section 8.14

Number 6. Physician's mother is having chronic gastrointestinal problems. Physician is a prominent gastrointerologist in the state. Mother asks Physician to treat her because she doesn't trust anyone else. What is Physician's preferred course of action?

a. Treat his mother. Trust is a critical element in the physician-patient relationship.
b. Recommend another qualified physician to treat his mother while continuing to act as a loving and concerned adviser.
c. Refuse to get involved.
d. Insist she get another doctor, but assure her that he will direct her care through her doctor.

Correct Answer: b. Recommend another qualified physician to treat his mother while continuing to act as a loving and concerned adviser.

Feedback: Generally, physicians should not treat themselves or members of their immediate family. A physician may lack objectivity when the patient is someone close to the physician, and the patient may not be as forthcoming about his or her medical problems. See AMA Medical Code of Ethics, Section 8.19.

Number 7. This term describes the situation where a physician informally asks for another physician's opinion about a patient's symptoms or test results, and the second physician does not examine the patient.

a. Malpractice
b. HIPAA violation
c. Curbside consultation
d. Breach of confidentiality
e. Second opinion

Correct Answer: c. Curbside consultation

Feedback: Some states have recognized that imposing liability for giving an informal opinion would have a chilling effect on the collegiality among physicians and, in the long term, have negative impact on patient care. Thus, a "curbside consultation" with another physician does not create a physician-patient relationship and, therefore, imposes no duty on the physician who informally shares his or her expertise with a colleague. Tennessee has yet to accept or reject the concept of a "curbside consultation." To the extent a physician affirmatively participates in the treatment or diagnosis, as opposed to expressing an opinion, Tennessee is likely to find a physician-patient relationship, even though the consulting physician did not examine the patient. See, Kelley v. Middle Tennessee Emergency Physicians, P.C., 133 S.W.3d 587 (Tenn. 2004).

Number 8. Patient has been Physician's patient for 10 years, but is considering changing physicians. Which of the following statements most accurately reflects Patient's obligations to Physician?

a. Patient is legally obligated to notify Physician that he has been dismissed.
b. Patient must give Physician at least a 30-day notice that he will be dismissed.
c. Patient can dismiss Physician for any reason without notification.
d. Patient can dismiss Physician for any reason as long as the reason is not illegal.

Correct Answer: c. Patient can dismiss Physician for any reason without notification.

Feedback: See AMA Code of Medical Ethics, Sections 8.115 and 9.06.

Number 9. Of the following reasons for refusing to accept a patient, which is the least likely to be an ethical or legal violation?

a. It is an emergency and physician is busy.
b. Patient's inability to speak English.
c. Patient's inability to pay for treatment.
d. Patient's religious beliefs require him to refuse blood transfusions or blood products.
e. Patient is deaf.

Correct Answer: c. Patient's inability to pay for treatment.

Feedback: Generally, a physician may refuse to accept a patient for any reason, except in cases of emergency. However, it is unethical to refuse a patient based upon an illegal reason, such as gender, race, religion, national origin, disability, etc. Refusal on these grounds may also violate anti-discrimination laws. Physicians have an obligation to share in providing charity care, but not to the degree that would seriously compromise the care provided to existing patients. See AMA Medical Code of Ethics, Sections 9.065 and 10.05.

Number 10. Employee, who works with asbestos, is evaluated by Physician each year for asbestos-related illnesses. Physician is hired by Employer, and Physician sends his report to Employer. The report shows that Employee has a suspicious spot on his lung. What is Physician's preferred course of action in this situation?

a. Do nothing. Physician owes no duty to Employee because there is no physician-patient relationship.
b. Physician should send Employee a copy of the test results with a clear explanation of the potential problem and encourage him to seek medical help.
c. Do nothing. It is Employee's responsibility to ask about the test results.
d. Physician should call Employee in for further tests, and if indicated, begin treatment immediately.
e. Do nothing. It is Employer's duty to share the tests results with Employee.

Correct Answer: b. Physician should send Employee a copy of the test results with a clear explanation of the potential problem and encourage him to seek medical help.

Feedback: There is no liability for medical malpractice because there is no physician-patient relationship when the employer retains the physician for a work-related evaluation. However, the American Medical Association maintains that the ethical course of action is to notify the patient of any adverse test results. Thus, the physician may be subject to disciplinary action for unethical conduct. Some state laws follow the AMA ethical guidelines for this situation finding liability based on simple negligence principles rather than medical malpractice. According to the AMA Code of Medical Ethics, Section 10.03, the physician in this situation has a responsibility to inform the patient about important health information or abnormalities that he or she discovers during the course of the examination. The physician should ensure to the extent possible that the patient understands the problem or diagnosis. When appropriate, the physician should encourage the patient to seek care from a qualified physician, and if requested, provide reasonable help in securing follow-up care.

Number 11. Specialist is asked to give a second opinion regarding the appropriateness of performing a specific procedure on Patient. Specialist examines Patient and agrees with Physician that the procedure would be appropriate for Patient. Physician performs the procedure, and Patient sustains severe injury. Patient sues both Physician and Specialist. Which of the following is Patient's strongest argument to hold Specialist liable?

a. The alleged negligence occurred during the implementation of the procedure.
b. The need for Specialist's services extended beyond performance of the procedure.
c. The Patient believed that Specialist continued to be her physician beyond the performance of the procedure.
d. Specialist did not withdraw as Patient's physician prior to the performance of the procedure.
e. The alleged negligence occurred in the decision to perform the procedure.

Correct Answer: e. The alleged negligence occurred in the decision to perform the procedure.

Feedback: The strongest argument to hold Specialist liable is to allege that the negligence occurred when the physician-patient relationship existed between Specialist and Patient. Specialist was retained to give a second opinion about the appropriateness of performing the procedure, and the physician-patient relationship clearly existed between the two when Specialist examined Patient and rendered the opinion. The incorrect choices reflect much weaker positions in arguing that the physician-patient relationship existed. If there is no relationship, there is no liability for medical malpractice.

Kelley v. Middle Tennessee Emergency Physicians, P.C., 133 S.W.3d 587 (Tenn. 2004) (the existence of a physician-patient relationship is an essential element of a medical malpractice case).

Number 12. Specialist is asked to give a second opinion regarding the appropriateness of performing a specific procedure on Patient. Specialist examines Patient and agrees with Physician that the procedure would be appropriate for Patient. Physician performs the procedure, and Patient sustains severe injury. Patient sues both Physician and Specialist. Which of the following is Specialist's strongest defense?

a. He gave a curbside consultation.
b. The need for his services ended after he gave his opinion.
c. Patient dismissed him as her doctor when she did not contact him after his initial examination.
d. He withdrew from Patient's case.

Correct Answer: b. The need for his services ended after he gave his opinion.

Feedback: This is not a curbside consultation because Specialist examined Patient. Specialist did not withdraw as Patient's doctor because he did not give Patient notice of his withdrawal to give her time to find another doctor. The fact that Patient did not contact Specialist after the initial examination is not conclusive that Patient dismissed him as her doctor. Specialist was retained to give a second opinion, and the strongest defense is that the need for his services ended after he gave that opinion. If there was no longer a need for his services, the physician-patient relationship terminated, and there is no liability if the alleged negligence occurred after the relationship was terminated.

Kelley v. Middle Tennessee Emergency Physicians, P.C., 133 S.W.3d 587 (Tenn. 2004) (the physician-patient relationship is an essential element in a medical malpractice case).

Number 13. Believing she has arranged coverage for her on-call shift, Cardiologist leaves town. Patient comes to the ER with severe chest pain, and despite the efforts of the ER physicians, Patient dies of a heart attack. Patient's family sues the hospital, the ER physicians, and Cardiologist. What is Cardiologist's strongest defense?

a. Patient did not consent to have Cardiologist as a physician.
b. She was not present when the alleged negligence occurred.
c. It is the hospital's responsibility to provide back-up for on-call physicians.
d. She did not affirmatively participate in the diagnosis or treatment of the patient.

Correct Answer: d. She did not affirmatively participate in the diagnosis or treatment of the patient.

Feedback: Generally, some courts have been unwilling to hold a physician liable if the physician has never examined the patient or directed the patient's care. However, other jurisdictions may find liability for on-call physicians who refuse or fail to treat a patient. EMTALA also may impose penalties on physicians who are responsible for covering the ER and who fail to treat patients in emergency situations.

Kelley v. Middle Tennessee Emergency Physicians, P.C., 133 S.W.3d 587 (Tenn. 2004).
Anderson v. Houser, 240 Ga. App. 613 (1999) (on-call physician who was out of town did not have the requisite physician-patient relationship to give rise to liability for medical malpractice.)
EMTALA Section 489.24(j)

Number 14. Which of the following is not an acceptable method for terminating the physician-patient relationship?

a. Physician and patient agree to end the relationship.
b. Patient unilaterally decides to receive his medical care from another physician.
c. Physician informs a noncompliant patient that physician will no longer see him as a patient.
d. A consulting physician signs off in the medical chart when his services are no longer needed.
e. Physician sends a letter to patient giving him 30 days to find another health care provider.

Correct Answer: c. Physician informs a noncompliant patient that physician will no longer see him as a patient.

Feedback: Although a physician may terminate the relationship with a noncompliant patient, the physician must give adequate notice so that the patient has time to find another health care provider. Some physicians question whether noncompliancy is a sufficient reason to terminate the relationship with a patient.

AMA Medical Code of Ethics, Section 8.115.

Number 15. The type of consent that must be obtained before touching the patient.

Correct Answer: General consent

Number 16. General consent must be obtained before touching the patient.

Number 17. The legal claim against a physician if either the patient isn't aware that the physician was going to perform the procedure or the patient hasn't authorized it.

Correct Answer: Medical Battery

Number 18. Medical battery is the legal claim against a physician if either the patient isn't aware that the physician was going to perform the procedure or the patient hasn't authorized it.

Number 19. Patient, who is 50 years old, refuses to get a pap smear. Of the following, which is the preferred course of action for the physician?

a. Explain the risks of not getting a pap smear.
b. Do nothing. The probability of her getting cervical cancer is low.
c. Have her sign a statement that she refused to get a pap smear.
d. Terminate the relationship because she is a noncompliant patient.
e. Do nothing. Pap smears are risk-free procedures so no informed consent is necessary.

Correct Answer: a. Explain the risks of not getting a pap smear.

Feedback: If the procedure has material risks, the patient should be educated about the benefits of the test and the risks of not getting the test through the informed consent process. However, if the rejected procedure is relatively risk-free, such as a pap smear, the physician should educate the patient on the risks of not getting it. In other words, the patient's refusal must be informed.

Truman v. Thomas, 27 Cal. 3d 285 (1980). This court stated that even though the probability of her getting cancer was low, the risk was death if she did get cancer. Thus, the doctor should have educated her about the risks of not getting a pap smear. Note: The doctor in this case claimed he had told her of the risks of not getting a pap smear, but the medical record didn't support his claim.

Number 20. The attending physician asks the nurse to obtain the patient's informed consent. Nurse does not completely understand the procedure and fails to mention that a recognized material risk of the procedure is death. Patient dies. If Patient's family sues, who is the one most likely to be held responsible for failing to obtain informed consent?

a. The attending physician
b. The nurse
c. Both the attending physician and the nurse
d. The hospital
e. No one because Patient signed the consent form.

Correct Answer: a. The attending physician

Feedback: The physician may delegate the task of getting informed consent, but the ultimate responsibility remains with the physician who performs the procedure or under whose direction a non-physician performs it. In Tennessee, as well as in many other states, a non-physician has no duty to obtain informed consent. Under certain circumstances, a hospital can assume a legal duty to obtain a patient's informed consent, such as when a hospital participates in an investigational clinical study monitored by the FDA.

See, Bryan v. HCA Health Services of Tennessee, 15 S.W.3d 804 (Tenn. 2000).

Number 21. A patient, in no uncertain terms, withdraws consent for a procedure after it has begun. What is the preferred course of action for the physician?

a. Stop treatment immediately.
b. Ignore the patient because after the procedure has started, it is too late to withdraw consent.
c. Determine whether it is medically feasible to discontinue the treatment.
d. Continue treatment while trying to convince the patient to change his mind.
e. Call psychiatry for an emergency consult.

Correct Answer: c. Determine whether it is medically feasible to discontinue the treatment.

Feedback: When medical treatments or examinations occurring with the patient's consent are proceeding in a manner requiring bodily contact between the doctor and the patient, and consent to the contact is withdrawn, it must be medically feasible for the doctor to stop the treatment or examination at that point without being detrimental to the patient's health or life. The patient must act or use language which can be subject to no other inference and which must be unquestioned responses from a clear and rational mind. There must be no doubt that consent was actually withdrawn. See, King v. Dodge County Hospital, (Ga. App. 2005).

Number 22. Must be obtained if the medical procedure or treatment involves a material risk of harm to the patient.

Correct Answer: Informed Consent

Number 23. Informed consent must be obtained if the medical procedure or treatment involves a material risk of harm to the patient.

Number 24. Infection, allergic reaction, severe loss of blood, loss or loss of function of any limb or organ, loss of reproductive function, paralysis or partial paralysis, paraplegia or quadriplegia, disfiguring scar, brain damage, cardiac arrest, or death.

Correct Answer: Material Risks

Number 25. Material risks include infection, allergic reaction, severe loss of blood, loss or loss of function of any limb or organ, loss of reproductive function, paralysis or partial paralysis, paraplegia or quadriplegia, disfiguring scar, brain damage, cardiac arrest, or death.

Number 26. Patient goes to the doctor for treatment of a sore throat. Patient opens his mouth to allow doctor to see his throat. Which of the following terms describes the type of consent given?

a. Express
b. None
c. Unnecessary
d. Implied
e. Informed

Correct Answer: d. Implied

Feedback: Physicians are not required to obtain written, express consent for each patient encounter. Often, general consent is implied by the actions and statements of the patient. However, informed consent should always be in writing and noted in the medical record.

See, Pope v. Davis, 261 Ga. App. 308 (2003).
See also, Blanchard v. Kellum, 975 S.W.2d 522 (Tenn. 1998) (raising a defense of implied consent raises issues of fact for the jury to decide).

Please note: Do not confuse this type of implied consent with Tennessee's implied consent law that states:
Any person who drives any motor vehicle in the state is deemed to have given consent to a test for the purpose of determining the alcoholic or drug content of that person's blood; provided, that such test is administered at the direction of a law enforcement officer having reasonable grounds to believe such person was driving while under the influence of an intoxicant or drug, as defined in § 55-10-405.

Tenn. Code Ann. § 55-10-406(a)(1) (2004).

Number 27. What is the primary purpose of the informed consent process?

a. To get it in writing.
b. To educate the patient.
c. To avoid lawsuits.
d. To shift responsibility to the patient.
e. To satisfy legal requirements

Correct Answer: b. To educate the patient.

Feedback: If the medical treatment or procedure involves a material risk of harm to the patient, the informed consent process should educate the patient about (1) the diagnosis; (2) the nature and purpose of the proposed treatment; (3) the material risks generally recognized and accepted by reasonably prudent physicians; (4) the likelihood of success; (5) the practical alternative treatments and their risks, benefits, and likelihood of success; and (6) the prognosis if the proposed treatment is not received. Informed consent should also include whether the proposed procedure or treatment is experimental.

See, Ashe v. Radiation Oncology Associates, 9 S.W.3d 119 (Tenn. 1999).

AMA, Informed Consent, http://www.ama-assn.org/ama/pub/category/4608.html (accessed November 8, 2007).

Tennessee Code Section 29-26-118 (plaintiff must prove by expert testimony that defendant did not provide informed consent in accordance with the recognized standard of acceptable professional practice in the defendant's profession and specialty, if any, in the same or similar community in which the defendant practices.

Georgia Code Section 31-9-6.1 (consent for medical or surgical treatment)

Number 28. Acknowledges patient autonomy in deciding what medical treatment to reject. Requires educating the patient about the prognosis and material risks resulting from the patient's choice not to get the diagnostic test or proposed treatment.

Correct Answer: Informed Refusal

Number 29. Informed refusal acknowledges patient autonomy in deciding what medical treatment to reject. Requires educating the patient about the prognosis and material risks resulting from the patient's choice not to get the diagnostic test or proposed treatment.

Number 30. Physician is going to remove a small mole from Patient's cheek. Does Physician need to get informed consent? Please choose the most appropriate answer based upon the facts provided.

a. No, because Patient asked to have the mole removed.
b. No, because there are no known, recognized material risks to the procedure.
c. Yes, because Physician could make a mistake in removing the mole.
d. Yes, because consent must be in writing.
e. Yes, because the mole may be malignant.

Correct Answer: b. No, because there are no known, recognized material risks to the procedure.

Feedback: The answer to this question is dependent upon the facts of each case. There may be similar cases where informed consent is appropriate. For example, if the mole is huge, and there is a risk of a disfiguring scar, the physician may want to obtain informed consent. In Tennessee, the test for getting informed consent is whether it is the acceptable standard of professional practice in the same or similar community in which the physician practices his profession or specialty.

Tennessee Code Section 29-26-118.

Number 31. The type of consent when a patient voluntarily submits to a procedure with actual or apparent knowledge of what is about to transpire. An example would be when a patient stands in a line where a doctor is giving people a shot, and the patient rolls up his sleeve to receive the shot.

Correct Answer: Implied

Number 32. Implied consent is the type of consent where a patient voluntarily submits to a procedure with actual or apparent knowledge of what is about to transpire. An example would be when a patient stands in a line where a doctor is giving people a shot, and the patient rolls up his sleeve to receive the shot.

Number 33. Which of the following is NOT necessary for a patient to give informed consent?

a. Literacy
b. Decision-making capacity
c. Knowledge
d. Voluntariness

Correct Answer: a. Literacy

Feedback: Giving a patient a consent form to read and sign, without explanation and discussion, does not satisfy a physician's duty to obtain informed consent. Patients who are illiterate or who do not speak English will learn nothing from a written form.

Number 34. Patient lacks the capacity to understand, make, or communicate his health care decisions. In Tennessee, of the following, who has the highest priority to consent to medical treatment on behalf of patient?

a. Guardian
b. Spouse
c. Health Care Agent
d. Adult children
e. Parents

Correct Answer: c. Health Care Agent

Feedback: Tennessee Code Section 68-11-1807. "Absent a court order to the contrary, a health care decision of an agent takes precedence over that of a guardian."

The question assumes that the court order appointing the guardian did not revoke the health care agent's authority. Other states, such as North Carolina, give priority to a court-appointed guardian. In Georgia, the health care agent has priority, even if there is a court-appointed guardian, unless the court order appointing the guardian states otherwise.

Number 35. In Tennessee, (1) a representative formally appointed by the patient, (2) a conservator or guardian judicially appointed by the court, (3) a patient-designated surrogate (4) a physician-designated surrogate, or (5) the designated physician after consultation with the ethics committee or an independent, nontreating physician.

Correct Answer: Consent Hierarchy

Number 36. In Tennessee, the consent hierarchy is:
(1) a representative formally appointed by the patient, (2) a conservator or guardian judicially appointed by the court, (3) a patient-designated surrogate (4) a physician-designated surrogate, or (5) the designated physician after consultation with the ethics committee or an independent, nontreating physician.

Number 37. Surgery performed by a surgeon who is not the surgeon patient believes will perform the surgery.

Correct Answer: Ghost Surgery

Number 38. Ghost surgery is surgery performed by a surgeon who is not the surgeon patient believes will perform the surgery.

Number 39. Surgery performed by a surgeon who is not the surgeon patient believes will perform the surgery.

a. Substituted surgery
b. Bait and switch surgery
c. Informed consent surgery
d. Ghost surgery
e. Residency program

Correct Answer: d. Ghost surgery

Feedback: "Ghost surgery" may be battery if the patient consented to a specific surgeon. In some states, this question has turned on whether the consent form signed by the patient was broad enough to cover the surgeon actually performing the surgery. However, the AMA's Code of Medical Ethics, Section 8.16, states that "a surgeon who allows a substitute to operate on his or her patients without the patient's knowledge and consent is deceitful." The Code further states: "With the consent of the patient, it is not unethical for the operating surgeon to delegate the performance of certain aspects of the operation to the assistant provided this is done under the surgeon's participatory supervision, i.e., the surgeon must scrub. If a resident or other physician is to perform the operation under non-participatory supervision, it is necessary to make a full disclosure of this fact to the patient, and this should be evidenced by an appropriate statement contained in the consent. Under these circumstances, it is the resident or other physician who becomes the operating surgeon."

Number 40. Informed consent acknowledges and promotes which of the following ethical principles?

a. Beneficence
b. Nonmaleficence
c. Autonomy
d. Justice
e. Substituted judgment

Correct Answer: c. Autonomy

Number 41. In the order of preference (depending upon the physician's determination that the person chosen has exhibited certain qualifications: (1) spouse, (2) adult children, (3) parents, (4) adult siblings, (5) any adult relative, and (6) any other adult who has exhibited special care and concern for the patient, is familiar with the patient's personal values, and is available and willing to serve.

Correct Answer: Physician-Designated Surrogate

Number 42. A physician-designated surrogate, in the order of preference (depending upon the physician's determination that the person chosen has exhibited certain qualifications: (1) spouse, (2) adult children, (3) parents, (4) adult siblings, (5) any adult relative, and (6) any other adult who has exhibited special care and concern for the patient, is familiar with the patient's personal values, and is available and willing to serve.

Number 43. During the course of an operation to repair a bilateral hernia, surgeon removed patient's left testicle. Does the following clause in the consent form signed by patient cover this additional procedure? "I consent to the performance of operations and procedures in addition to or different from those contemplated, whether or not arising from presently unforeseen conditions, which the above named physician or his associates or assistants may consider necessary or advisable in the course of the operation."

a. Yes, because the consent form covers every potential contingency.
b. Yes, because the patient signed the consent form.
c. No, because the patient was not aware the surgeon was going to remove his left testicle.
d. No, because it is a blanket consent form.
e. Yes, because it was medically advisable to do the additional procedure.

Correct Answer: c. No, because the patient was not aware the surgeon was going to remove his left testicle.

Feedback: Massingale v. Lee, No. E2004-01364-COA-R3-CV (2005). Although a signed consent form gives rise to a presumption of consent, blanket consent forms are frowned upon by the courts. Despite the signed consent form, this issue went to the jury to determine whether the patient was aware that his left testicle may be removed, and if so, did he authorize the procedure. The patient's claim for medical malpractice was dismissed, and the case proceeded to the jury for a determination on the claim for medical battery.

Number 44. If a patient can show that she was not aware that the physician was going to perform the procedure or that she did not authorize it, which of the following legal claims does she have?

a. Medical malpractice
b. Medical battery
c. Simple negligence
d. Breach of contract
e. Breach of fiduciary duty

Correct Answer: b. Medical battery

Feedback: See, Hensley v. Scokin, 148 S.W.3d 352 (Tenn. Ct. App. 2003).

Number 45. Patient, a 22-year-old man, lacks the capacity to make his health care decisions. Physician meets with the family to determine who has the right to make health care decisions on patient's behalf. Physician determines there is no formally appointed health care agent or guardian, and patient did not designate a surrogate. His young wife is near hysteria and has been calmed with a sedative. His mother is crying and wringing her hands. His older sister and father appear calm, intelligent, and caring. His best friend tells the physician that he has had some conversations with patient about his preferences for health care in this situation, but he will be leaving town the following morning for an extended business trip. Who should physician designate as patient's surrogate under Tennessee law?

a. Spouse
b. Mother
c. Sister
d. Father
e. Best friend

Correct Answer: d. Father

Feedback: Tennessee Code Annotated, Section 68-11-1706. Neither patient's spouse nor mother appear to be emotionally capable of making patient's health care decisions for him at this time. Under Tennessee law, the physician could choose father, sister, or patient's best friend, depending upon who physician determines is best qualified to make patients health care decisions. Assuming that all three meet the qualifications, Father is highest in the order of preference to be designated as patient's surrogate.

Number 46. Which of the following is the most determinative of whether a patient's informed consent is needed before a procedure or treatment is started?

a. Potential for medical malpractice
b. Material risks
c. Inexperience of physician
d. Capacity of patient
e. Hospital regulations

Correct Answer: b. Material risks

Number 47. Patient, a 33-year old woman, lacks the capacity to make her health care decisions. Physician seeks out the family to determine who has the legal right to make them for her. Her husband has been appointed her conservator (legal guardian) in a court of law. Her mother, father, brother, and sister are in the waiting room. While patient had capacity, she named her close "friend" John as her attorney-in-fact in her durable power of attorney for health care. Her husband demands that John leave because Husband, as her legal guardian, has the legal right to make patient's health care decisions. Who has the legal right at this point?

a. Close "friend" John
b. Husband
c. Father
d. Mother
e. Brother
f. Sister

Correct Answer: a. Close "friend" John

Feedback: Tennessee Code Annotated Section 68-11-1707. Absent a court order to the contrary, a health care decision of an agent (attorney-in-fact) takes precedence over that of a guardian. The physician should ask husband if the court who appointed him as her guardian also gave him the power to make health care decisions in spite of directions in a durable power of attorney for health care. If not, the health care agent (attorney-in-fact) has the superior legal right to make patient's health care decisions for her.

Number 48. Someone who is younger than 18 years old.

Correct Answer: Minor

Number 49. A minor is someone who is younger than 18 years old.

Number 50. A minor who is financially independent and who is no longer under the control or authority of his or her parents or guardian (this may be evidenced by a court order), a married minor, or a minor in the armed services.

Correct Answer: Emancipated Minor

Number 51. An emancipated minor is someone under 18 years of age who is financially independent and who is no longer under the control or authority of his or her parents or guardian (this may be evidenced by a court order), a married minor, or a minor in the armed services.

Number 52. Patient is 17 years old, and she sees physician for a sore throat. Under which of the following fact scenarios will Physician need to get parental consent to treat Patient?

a. Patient is a private in the U.S. Army.
b. Patient's spouse is in the waiting room.
c. Patient has a court order declaring her financially independent from her parents.
d. Patient has a developmental disability giving her the mental capacity of a 6 year-old.
e. Physician does not need parental consent to treat the patient under any circumstance.

Correct Answer: d. Patient has a developmental disability giving her the mental capacity of a 6 year-old.

Feedback: Under this fact scenario, Patient is not emancipated, nor does she fall within "mature minor" doctrine, nor does a statutory exception apply. Thus, the physician must follow the general rule of getting parental consent before treating a minor.
Cardwell v. Bechtol, 724 S.W.2d 739 (Tenn. 1987).

Number 53. A 14-year-old girl visits the family physician seeking a prescription for birth control. She tells her doctor that she is having sex with her 14-year old boyfriend. Which of the following choices best describes the physician's legal options under Tennessee law?

a. Physician may provide the prescription but only with parental consent.
b. Physician should refuse to give the prescription because the patient is not a mature minor.
c. Physician may provide the prescription without parental consent.
d. Physician may provide the prescription without parental consent, but must notify the parents.
e. Physician should refuse to provide the prescription and report the boyfriend for statutory rape.

Correct Answer: c. Physician may provide the prescription without parental consent.

Feedback: Tennessee Code Section 68-34-107. ("Contraceptive supplies and information may be furnished by physicians to any minor . . . who requests and is in need of birth control procedures, supplies or information.")

Tennessee Code Section 39-13-506 defines statutory rape as "the unlawful sexual penetration of a victim by the defendant or of the defendant by the victim when . . . the victim is at least thirteen (13) but less than fifteen (15) years of age and the defendant is at least four (4) years older than the victim . . ." Please Note: This is not the only definition of statutory rape. The definition and degree of statutory rape depends upon the age of the victim and the age of the defendant.

Number 54. A 14-year-old girl visits her family doctor because she is concerned she is pregnant. Test results prove her correct. She tells you the father is her 14-year-old boyfriend. Which of the following choices best describes the doctor's legal and ethical options under Tennessee law?

a. Provide prenatal care only with parental consent.
b. Provide prenatal care without the consent or knowledge of the parents.
c. Provide prenatal care without parental consent, but only after notifying the parents.
d. Provide prenatal care without parental consent, but report her boyfriend for statutory rape.

Correct Answer: b. Provide prenatal care without the consent or knowledge of the parents.

Feedback: Tennessee Code Section 63-6-223. "Any person licensed to practice medicine . . . may, for the purpose of providing prenatal care, examine, diagnose, and treat a minor without the knowledge or consent of the parents or legal guardian of the minor, and shall incur no civil or criminal liability in connection therewith except for negligence."

Tennessee Code Section 39-13-506 defines statutory rape as "the unlawful sexual penetration of a victim by the defendant or of the defendant by the victim when . . . the victim is at least thirteen (13) but less than fifteen (15) years of age and the defendant is at least four (4) years older than the victim . . ." Please Note: This is not the only definition of statutory rape. The definition and degree of statutory rape depends upon the age of the victim and the age of the defendant.

Number 55. Regarding the medical treatment of minors, Tennessee follows which of the following rules?

a. Mature minor doctrine
b. Treat only with parental consent unless covered by a statutory exception
c. Treat with parental notification
d. Treat only with written parental consent

Correct Answer: a. Mature minor doctrine

Feedback: Cardwell v. Bechtol, 724 S.W.2d 739 (Tenn. 1987).

If a doctor treats a minor without parental consent using the mature minor doctrine as the basis for doing so (a statutory exception does not apply), there is a risk that the doctor may be sued successfully for medical battery if the parents object. If the minor is between the ages of 7 and 14, the doctor has the burden of proving the minor is mature. If the minor is between the ages of 14 and 18, the parents have the burden of proving that the minor is not mature. Regardless of the age of the minor, there is a risk of a lawsuit for medical battery.

Number 56. A 6-year-old boy visits his family doctor because he has a sore throat. Under Tennessee law, which of the following choices best describes doctor's legal options?

a. Treat without parental consent and maintain confidentiality.
b. Treat without parental consent, but notify the parents.
c. Treat without parental consent because it is an emergency.
d. Treat only with parental consent.
e. Treat without parental consent only if doctor determines that the patient is a mature minor.

Correct Answer: d. Treat only with parental consent.

Feedback: Cardwell v. Bechtol, 724 S.W.2d 739 (Tenn. 1987).

A child under the age of seven does not have the capacity to consent to medical treatment. No statutory exception to this general rule applies in this case, so the doctor must get parental consent before treating. Failure to do so may expose the doctor to a claim of medical battery. Note: If the severity of the sore throat rises to the level of an emergency, i.e., puts the life or health of the boy at risk, an emergency exception may apply.

Number 57. A 10-year-old boy visits his family doctor because he has a sore throat. Under Tennessee law, which of the following choices best describes doctor's options?

a. Treat without parental consent.
b. Treat without parental consent, but notify the parents.
c. Treat without parental consent because it is an emergency.
d. Treat only with parental consent.
e. Treat with parental consent unless doctor can show that the patient is a mature minor.

Correct Answer: e. Treat with parental consent unless doctor can show that the patient is a mature minor.

Feedback: Cardwell v. Bechtol, 724 S.W.2d 739 (Tenn. 1987).

There is a rebuttable presumption that a child between the ages of 7 and 14 does not have the capacity to consent to medical treatment. Thus, if a doctor treats a child within this age range without parental consent, the burden is on the doctor to show that the child was sufficiently mature to understand and comprehend the nature of the treatment and the risks involved.

No statutory exception applies in this case, so the doctor either must get parental consent before treating or be prepared to show that the patient is a mature minor if the parents object to the treatment. If the doctor treats without parental consent and cannot show that the patient is a mature minor, the doctor may be liable for a medical battery.

Number 58. A 16-year-old boy visits his family doctor because he has a sore throat. Under Tennessee law, which of the following choices best describes doctor's options?

a. Treat without parental consent.
b. Treat without parental consent, but notify the parents.
c. Treat without parental consent because it is an emergency.
d. Treat only with parental consent.
e. Treat without parental consent only if doctor can prove that the patient is a mature minor.

Correct Answer: e. Treat without parental consent only if doctor can prove that the patient is a mature minor.

Feedback: Cardwell v. Bechtol, 724 S.W.2d 739 (Tenn. 1987).

There is a rebuttable presumption that a child between the ages of 14 and 18 has the capacity to consent to medical treatment. Thus, if a doctor treats a child within this age range without parental consent, the burden is on the parents to show that the child was not sufficiently mature to understand and comprehend the nature of the treatment and the risks involved.

No statutory exception applies in this case, but the doctor may treat without parental consent after determining that the patient is a mature minor. If the parents object to the treatment and can show that the patient is not sufficiently mature to make medical decisions, the doctor may be liable for a medical battery.

Number 59. The "mature minor" doctrine in Tennessee is limited by which of the following?

a. Emancipation
b. Parental rights
c. Rule of Sevens
d. Common sense
e. Constitution

Correct Answer: c. Rule of Sevens

Feedback: Cardwell v. Bechtol, 724 S.W.2d 739 (Tenn. 1987)

The Rule of Sevens limits the mature minor doctrine: (1) Under the age of 7: no capacity to make medical decisions. (2) Between the ages of 7 and 14: a rebuttable presumption of no capacity to make medical decisions. (3) Between the ages of 14 and 21 (now 18 in Tennessee): a rebuttable presumption of capacity to make medical decisions.

Number 60. A 12-year-old boy visits the family physician for help with his drug abuse problem. Under Tennessee law, which of the following best describes the physician's legal options?

a. Treat only with parental consent.
b. Treat without parental consent and notify the parents about the treatment at the doctor's discretion.
c. Treat without parental consent and do not disclose to the parents without the patient's consent.
d. Treat only with parental consent and report the patient to juvenile authorities.
e. Refuse to treat unless patient signs a consent form allowing parental notification.

Correct Answer: b. Treat without parental consent and notify the parents about the treatment at the doctor's discretion.

Feedback: Tennessee Code Section 63-6-220. (allows a physician to treat a juvenile drug abuser without parental consent. The physician may use his or her own discretion in determining whether to notify the juvenile's parents about the treatment.)

Number 61. Patient, a 15-year-old boy, visits his family physician and expresses concern that he may have been exposed to HIV when he shared a needle with a friend who later told him he was HIV positive. Under Tennessee law, which one of the following statements best describes physician's legal options?

a. Treat only with parental consent.
b. Treat without parental consent but notify parents if the HIV test comes back positive.
c. Treat without parental consent and maintain confidentiality.
d. Refuse to treat unless patient is accompanied by a parent.
e. Treat without parental consent only after patient has obtained judicial bypass.

Correct Answer: c. Treat without parental consent and maintain confidentiality.

Feedback: Tennessee Code Annotated Section 68-10-104(c): "Any state, district, county or municipal health officer or any physician may examine, diagnose, and treat minors infected with STDs without the knowledge or consent of the parents of the minors, and shall incur no civil or criminal liability in connection with the examination, diagnosis, or treatment, except for negligence." Tennessee includes HIV in its definition of STDs.

Number 62. Patient, a 12-year old girl, comes to a free health clinic with symptoms of an STD. She tests positive for chlamydia. What are Physician's legal options?

a. Treat only with parental consent.
b. Treat without parental consent, but report the suspected case of child sexual abuse to the appropriate authorities.
c. Treat without parental consent and maintain patient confidentiality.
d. Treat without parental consent, but notify the girls' parents.

Correct Answer: b. Treat without parental consent, but report the suspected case of child sexual abuse to the appropriate authorities.

Feedback: Tenn. Code Ann., Section 68-10-104(c) allows a physician to treat a minor infected with an STD without the knowledge or consent of the parents. However, other Tennessee statutes requires that someone who knows or who has reasonable cause to suspect that a child has been sexually abused must report the suspicion to the department of children services. See, Tenn. Code. Ann. Section 37-1-605. In addition, the physician is required to report the case to the health department under Section 37-1-403(f) (requires that anyone who makes a diagnosis of, or treats, or prescribes for any STD or venereal herpes and chlamydia in children age 13 years or younger must report the case to the department of health).

Child sexual abuse is defined as the commission of any act involving the unlawful sexual abuse, molestation, fondling, or carnal knowledge of a child under the age of 13 years old. See, Tenn. Code Ann. Section 37-1-602(3)(B).

Number 63. A form of doing business that is subject to double taxation is a

a. Sole proprietorship
b. Partnership
c. Corporation
d. Limited partnership

Correct Answer: c. Corporation

Feedback: A corporation is a separate legal entity and is taxed under the corporate income tax schedule. If a corporation pays its shareholders dividends from corporate profits, the dividend is taxed at the shareholder level on the shareholders' individual income tax returns. Thus, the same money is taxed twice -- once at the corporate level and once at the shareholder level. However, double taxation can be avoided by small corporations by electing subchapter S status at the time of incorporation, or by paying corporate profits to shareholder employees in the form of reasonable compensation rather than dividends. An attorney can help a medical practice determine which legal form of doing business is the most appropriate choice.

Number 64. The owners of a professional corporation.

Correct Answer: Shareholders

Number 65. Shareholders are the owners of a professional corporation.

Number 66. An agreement not to set up another practice locally if a physician leaves his or her current practice.

a. Covenant not to compete
b. Non-solicitation covenant
c. No-hire covenant
d. Non-disclosure covenant
e. Covenant not to practice

Correct Answer: a. Covenant not to compete

Feedback: Before January 1, 2008. covenants not to compete were not enforceable against physicians in Tennessee except in two circumstances. The Tennessee legislature recognized two situations in which the public interest weighed in favor of enforcing covenants not to compete against physicians: (1) when the employer is a hospital or an affiliate of a hospital, and (2) when the employer is a faculty practice plan associated with a medical school. Tenn. Code Ann. Section 63-6-204. See, Murfreesboro Medical Clinic, P.A. v. Udom, 166 S.W.3d 674 (Tenn. 2005).

However, beginning January 1, 2008, a new law in Tennessee makes covenants not to compete enforceable against any health care provider who signs such an agreement if certain conditions are met: (1) the duration of the restriction is two years or less; and (2) the restriction meets geographic limitations (10 mile radius) or facility limitations (at all facilities where the practice provided services while the physician was employed by the practice). The new law does not apply to physicians who specialize in emergency medicine. Tenn. Code Ann. Section 63-1-148.

The AMA strongly discourages covenants not to compete, and under Section 9.02 of the Code of Medical Ethics, it states: "Covenants-not-to-compete restrict competition, disrupt continuity of care, and potentially deprive the public of medical services."

In many states, covenants not to compete are enforceable if they are reasonable as to time and geographic area. For example, a covenant not to compete that states the physician may not practice medicine within a 25-mile radius of his or her former practice for three years likely would be enforceable in many states (but not in Tennessee). The geographic limitation may be larger if it can be shown that the patient base of the practice being protected is spread over a larger area. Georgia courts have upheld a covenant not to compete that prohibited the physician from practicing medicine within a 75-mile radius of Albany when it was shown that the practice's patient base and referral area was within a 75-mile radius. See. Keeley v. Cardiovascular Surgical, 236 Ga. App. 26 (1999).

Number 67. The managed care model

a. Promotes patient autonomy
b. Relies upon a physician's judgment to do what is in the best interest of the patient
c. Controls health care costs
d. Disregards the cost as long as the care is medically beneficial

Correct Answer: c. Controls health care costs

Feedback: Compare the managed care model to the fee for service model. Under the fee for service model, the physician was paid on a retrospective basis, in full, for all medically necessary services provided to the patient. Every insured individual was entitled to all medical care that could be beneficial, regardless of how much that care might cost. The managed care model, which became popular in the 1990's, attempts to control health care costs by limiting a patient's utilization of medical services through various methods, such as requiring approval of medical services before they are provided.

Number 68. The main advantage of a corporation over a partnership is

a. Taxes are passed through to the owners' individual income tax returns
b. Liability may be limited to the assets invested in the business
c. Initial setup is simplified
d. Form of business is easier to maintain

Correct Answer: b. Liability may be limited to the assets invested in the business

Feedback: In a general partnership, each partner's personal assets are at risk for paying off the debts and liabilities of the partnership. Partnership liabilities may include damage awards or settlements against other partners for medical malpractice.

Number 69. A form of doing business that is a distinct legal entity separate from its owners. Because it is a separate legal entity, it has the advantage of limiting liability for its owners, but the disadvantage of double taxation.

Correct Answer: Corporation

Number 70. A corporation is a form of doing business that is a distinct legal entity separate from its owners. Because it is a separate legal entity, it has the advantage of limiting liability for its owners, but the disadvantage of double taxation.

Number 71. The sole owner of the simplest form of doing business.

Correct Answer: Sole Proprietor

Number 72. A sole proprietor is the sole owner of the simplest form of doing business.

Number 73. Two or more people engaged in business for profit.

Correct Answer: Partnership

Number 74. A partnership is two or more people engaged in business for profit.

Number 75. A form of doing business that has the tax advantages of a partnership and sole proprietorship, while having the advantages of a corporation in limiting the liability of its owners.

Correct Answer: Limited Liability Company

Number 76. A limited liability company is a form of doing business that has the tax advantages of a partnership and sole proprietorship, while having the advantages of a corporation in limiting the liability of its owners.

Number 77. The abbreviation for limited liability company.

Correct Answer: LLC

Number 78. LLC is the abbreviation for limited liability company.

Number 79. Which form of business is least recommended for a medical practice?

a. Limited liability company
b. corporation
c. sole proprietorship
d. general partnership

Correct Answer: d. general partnership

Feedback: A general partnership is the least recommended form of doing business for a medical practice because each partner may be held personally liable for the medical malpractice of all the other partners. A sole proprietorship is not recommended because it offers no protection for the physician's personal assets. Professional corporations, limited liability companies, or limited liability partnerships are more appropriate choices. An attorney can advise physicians on the most appropriate form of doing business for their medical practices.

Number 80. Owners of a limited liability company.

Correct Answer: Members

Number 81. The owners of a limited liability company are called "members."

Number 82. Physician has received Patient's positive HIV test results. Under Tennessee statute, to whom must Physician report the positive results in addition to the Patient?

a. Patient's spouse
b. People who have shared needles with Patient.
c. Patient's sexual partner(s)
d. Designated personnel in the health department
e. All of the listed people or entities
f. No one. This information is confidential.

Correct Answer: d. Designated personnel in the health department

Feedback: Tennessee statute does not require a health care provider to report a confirmed or suspected case of HIV to anyone except the health department. The health department is required to take necessary measures to prevent the spread of the disease. Tenn. Code Ann. Sections 68-5-102 and 68-10-101. Tennessee provides specific forms for making the report which are available at the Web site of the Tennessee Department of Health (http://health.state.tn.us/).

Georgia law does not authorize a physician to disclose "AIDS confidential information" to anyone except people specifically named in the statute. In this case under the Georgia statute, a physician may inform the patient's spouse and sexual partners that they may have been exposed to HIV. An unauthorized disclosure is a misdemeanor. Ga. Code Ann. Section 24-9-47.

Number 83. A federal agency that provides valuable information about infectious diseases and traveler's health information.

a. HUD
b. CDC
c. FEC
d. FTC
e. SEC

Correct Answer: b. CDC

Feedback: Center for Disease Control and Prevention http://www.cdc.gov/

Number 84. A federal agency that provides valuable information about infectious diseases and traveler's health information.

Correct Answer: CDC

Number 85. The Center for Disease Control and Prevention (CDC) is a federal agency that provides valuable information about infectious diseases and traveler's health information.

Number 86. Physician recommends to Patient that he get an HIV test. What is the preferred course of action for Physician?

a. Have Patient sign a general consent form.
b. Rely on Patient's implied consent when he does not object.
c. Rely on Patient's oral consent.
d. Have Patient sign a separate consent form for HIV testing.
e. No consent is necessary because of public health concerns.

Correct Answer: d. Have Patient sign a separate consent form for HIV testing.

Feedback: Although Tennessee does not have a specific statutory requirement for getting a separate consent for HIV testing, the Tennessee Department of Health provides a separate consent form (http://health.state.tn.us/). The AMA Code of Medical Ethics, Section 2.23, states that "Consent for HIV testing cannot be inferred from a general consent to treatment. The consent should be specific for HIV." An advantage of having a separate consent form is that the form clearly spells out the limits on confidentiality.

On the other hand, the Center for Disease Control and Prevention recommends that HIV testing be part of the general consent process, giving the patient the opportunity to opt out. (http://www.cdc.gov). The CDC's position is motiviating a number of states to changes their laws so that a separate consent is not required. The CDC position may be the catalyst for the AMA to change their ethical guidelines on this point.

Number 87. Patient requests an HIV test, but only if the results are kept strictly confidential. He does not want the health department harassing his sexual partners. Patient specifically prohibits Physician from reporting positive test results to the health department. What is Physician's preferred course of action?

a. Perform a rapid HIV test which allows anonymous testing.
b. Honor Patient's request for confidentiality.
c. Proceed only with Patient's written informed consent and full knowledge about the reporting requirements.
d. Refuse to perform the HIV testing.
e. Give the test and report any positive results to the health department.

Correct Answer: c. Proceed only with Patient's written informed consent and full knowledge about the reporting requirements.

Feedback: Tennessee law requires health care providers to report positive HIV tests to the health department on the appropriate forms. Tenn. Code Ann. Section 68-10-101. Although the results of a rapid HIV test may be obtained within 20 minutes, rapid testing may not be used as a means of providing anonymous HIV testing. Failure to follow the law may result in criminal penalties. See, http://health.state.tn.us/STD/guidelines.htm

Ethically, Physician should inform Patient that positive test results must be reported to the health department, regardless of the Patient's wishes for confidentiality. Tennessee's HIV consent form covers this information. Under the AMA Code of Medical Ethics, Section 2.23, the patient should know about the limits of patient confidentiality before consent to HIV testing is given.

Number 88. Patient's HIV test comes back positive. He believes that he contracted the disease when he visited a prostitute on a trip to Vegas. He begs Physician not to tell his wife. What is Physician's preferred course of action?

a. Honor Patient's confidentiality and tell no one.
b. File a report with the health department noting Patient's marital status and his unwillingness to tell his wife.
c. Warn Patient's wife about his HIV status.
d. Encourage him to tell his wife, but let him know Physician will tell her if he doesn't.

Correct Answer: b. File a report with the health department noting Patient's marital status and his unwillingness to tell his wife.

Feedback: Tennessee statute provides: "A person who has a reasonable belief that a person has knowingly exposed another to HIV may inform the potential victim without incurring any liability." Tenn. Code Ann. Section 68-10-115. At this point, has Patient "knowingly" exposed his wife to HIV? If the answer is "no," the statute may not afford immunity, and Patient may have a claim for breach of confidentiality against Physician.

Section 68-10-101 requires a physician to file the appropriate form with the health department to report a positive HIV test. Tennessee statute also provides: "If any attending physician or other person knows or has reason to suspect that a person having a STD is behaving so as to expose other persons to infection, or is about to behave, the attending physician or other person shall notify the municipal or county health officer of the name and address of the diseased person and the essential facts of the case." Tenn. Code Ann. Section 68-10-102. The health department should notify Patient's wife so that she may take precautions against contracting the disease.

The AMA Code of Medical Ethics, Section 2.23, states that "Physicians should ensure that HIV testing is conducted in a way that respects patient autonomy and assures patient confidentiality as much as possible."

If Patient signed the HIV informed consent form before the testing, he should know that Physician has no choice under the law but to report a positive result to the health department. Physician should encourage him to tell his wife before she learns about his HIV status from the health department.

Compare these statutes with the Tennessee Supreme Court case that held a physician had a duty to warn immediate family members that the patient died of Rocky Mountain Spotted Fever and their risks of exposure to the disease. See, Bradshaw v. Daniel, 854 S.W.2d. 865 (Tenn. 1993). Compare, Estate of Julie Amos v. Vanderbilt University, 62 S.W.3d 133 (Tenn. 2001) (physicians had duty to warn patient of her potential exposure to HIV tainted blood so that she may warn people in the foreseeable zone of danger, such as a future husband and child).

Number 89. The anxiety that results from a distinct event that may have put the patient at risk of contracting HIV.

Correct Answer: Fear of AIDS

Number 90. "Fear of AIDS" is the anxiety that results from a distinct event that may have put the patient at risk of contracting HIV.

Number 91. The "reasonable fears test" permits a patient to recover damages for the fear of AIDS during what time frame?

a. As long as patient can show physical effects of anxiety
b. Until the first HIV test comes back negative
c. The window of anxiety
d. As long as the patient feels the need to get tested

Correct Answer: c. The window of anxiety

Feedback: The window of anxiety test is used in some jurisdictions to measure damages sustained by someone who has been put at risk for AIDS. Generally, the window of anxiety is open until testing shows almost to a certainty that the victim does not test positive for HIV. Usually, this has been about six months to a year from the time of exposure. This time frame may change as the testing for HIV improves.

Number 92. For fear of AIDS cases, Tennessee follows which test?

a. Actual Exposure
b. Reasonable Fears
c. Reasonable Fears of a Well-informed Person
d. Distinct Event

Correct Answer: a. Actual Exposure

Feedback: Tennessee follows the "actual exposure" test. Two elements are required for recovery. The Patient must show that he or she was actually exposed to the HIV virus AND the exposure was through a recognized channel of transmission. See, Bain v. Wells, 936 S.W.2d 618 (Tenn. 1997).

Number 93. An HIV positive surgeon who continues to perform invasive procedures on patients MAY be guilty of which of the following crimes?

a. Felony
b. Misdemeanor
c. AIDS Transmitting Crime
d. No crime
e. Attempted Manslaughter

Correct Answer: a. Felony

Feedback: Under Tennessee law, it is a felony "for any person with knowledge that he or she is infected with HIV to knowingly engage in intimate contact with another." "Intimate contact" is defined as "the exposure of the body of one person to a bodily fluid of another person in any manner that presents a significant risk of HIV transmission." Tenn. Code Ann. Section 39-13-109. This definition is sufficiently broad to cover situations that do not involve sexual contact. Under the criminal statute, there need only be a "risk" of exposure; there does not need to be actual exposure. See, State v. Bonds, 189 S.W.3d 249 (Tenn. Crim. App. 2005).

The question to be addressed is whether an invasive surgical procedure would present a significant risk of HIV transmission from surgeon to patient. Courts in some jurisdictions have answered this question in the affirmative. See, Faya v. Almaraz, 329 Md. 435 (1993). Whether Tennessee felony statute would or should apply in this situation is up for debate, but the possibility remains until either the courts or the legislature specifically address this issue.

Some jurisdictions require an HIV positive physician to disclose his or her HIV status to patients as part of the informed consent process if the procedure or treatment poses a risk that the patient may be exposed to the HIV virus. Faya v. Almaraz, 329 Md. 435 (1993). See also, Waddell v. Bhat, 257 Ga. App. 580 (2002) (the court stated in dicta: "If we accept that health care providers are entitled to know if their patients are HIV-positive, how can an affected patient be denied the same knowledge about their treating health care provider? How else could they make an informed consent to risk such potentially fatal exposure for themselves or their children?" This case indicates that Georgia may be willing to require disclosure of a health care provider's HIV status as part of the informed consent process.)

Regardless of the disclosure issue, it is unethical for an HIV positive physician to perform a procedure that may put a patient at risk of contracting HIV. See AMA Code of Medical Ethics, Section 9.131.

Number 94. A physician who is HIV positive has an ethical duty to

a. Leave the practice of medicine.
b. Refrain from performing any procedure or treatment that would put a patient at risk.
c. Disclose his HIV status to his patients.
d. Take extra precautions while performing an invasive procedure on a patient.

Correct Answer: b. Refrain from performing any procedure or treatment that would put a patient at risk.

Feedback: It is unethical for an HIV positive physician to perform a procedure that may put a patient at risk of contracting HIV. See AMA Code of Medical Ethics, Section 9.131.

Under Tennessee criminal statute, an HIV positive phyician who performs a procedure that puts a patient at risk of contracting HIV may risk committing a felony. Tenn. Code Ann. Section 39-13-109.

Tennessee has not addressed the disclosure issue, but some jurisdictions require an HIV positive health care provider to disclose his or her HIV status to patients as part of the informed consent process if the procedure or treatment poses a risk that the patient may be exposed to the HIV virus. Faya v. Almaraz, 329 Md. 435 (1993). See also, Waddell v. Bhat, 257 Ga. App. 580 (2002) (the court stated in dicta: "If we accept that health care providers are entitled to know if their patients are HIV-positive, how can an affected patient be denied the same knowledge about their treating health care provider? How else could they make an informed consent to risk such potentially fatal exposure for themselves or their children?" This case indicates that Georgia may be willing to require disclosure of a health care provider's HIV status as part of the informed consent process.)

Number 95. Which of the following set of circumstances would likely not pass the "reasonable fears" test?

a. A needle stick after the needle had been used on an HIV positive patient.
b. An HIV positive surgeon performing an invasive procedure.
c. An HIV patient spitting on the doctor's shoulder.
d. A cleaning lady getting stuck by a needle in the trash.
e. An HIV positive dental hygienist cleaning a patient's teeth.

Correct Answer: c. An HIV patient spitting on the doctor's shoulder.

Feedback: Tennessee does not follow the "reasonable fears test." Under Tennessee law, a plaintiff would have to show he or she was actually exposed to HIV through a medically recognized channel of transmission. See, Bain v. Wells, 936 S.W.2d 618 (Tenn. 1997). However, even in jurisdictions that follow the "reasonable fears test," the fear must be reasonable. See, Hartwig v. Oregon Eye Clinic, 580 N.W.2d 86 (Neb. 1998).

Number 96. Patient, a 29-year-old male attorney, is diagnosed with SARS. He developed symptoms two days ago. He works in an office suite with his law partner and two administrative assistants. He left work after he started sneezing and feeling feverish, and he does not recall seeing any clients the day he got sick. In addition to isolating Patient, what is the preferred course of action to prevent the spread of SARS?

a. Quarantine his law partner and administrative assistants.
b. Quarantine everyone who may have come into close contact with Patient for the past two days.
c. No action is necessary because no one has been put at risk for getting SARS.
d. Allow his law partner and administrative assistants to go about their business, but caution them to be alert for SARS symptoms and report them immediately.
e. Alert everyone who has been in close contact with Patient for the past 14 days to watch for SARS symptoms and to report them immediately.

Correct Answer: d. Allow his law partner and administrative assistants to go about their business, but caution them to be alert for SARS symptoms and report them immediately.

Feedback: For more information about the control of SARS, go to the CDC web site, http://www.cdc.gov/ncidod/SARS/

Number 97. Which of the following communicable diseases must be reported to the health department immediately by telephone and followed by a written report?

a. Influenza
b. Yellow fever
c. Rabies
d. Mumps
e. Cholera

Correct Answer: d. Mumps

Feedback: Mumps is listed as a Category 1 notifiable disease by the Tennessee Department of Health. Category 1 diseases must be reported immediately by telephone, followed by a written report. The other diseases listed are Category 2, which only requires a written report. See Form PH-1600, available at http://health.state.tn.us/STD/forms.htm

Number 98. Which category of communicable or infectious disease requires immediate telephonic reporting that is followed by the appropriate written report?

a. Category 2
b. Category 1
c. Category 4
d. Category 3

Correct Answer: b. Category 1

Feedback: Form PH-1600 is available at http://health.state.tn.us/STD/forms.htm

Number 99. Under Tennessee law, how does a physician give a patient an anonymous HIV test?

a. Rapid HIV testing
b. There is no anonymous testing for HIV in Tennessee
c. Designated anonymous test sites
d. Submitting the test to a lab with only a number identification
e. Submitting the test under a false name

Correct Answer: b. There is no anonymous testing for HIV in Tennessee

Feedback: See, Tennessee Department of Health Web site: http://www.health.state.tn.us/STD/guidelines.htm

Number 100. Who in the following list is not required under Tennessee law to get an HIV test?

a. A pregnant woman who has refused in writing.
b. A man arrested for rape
c. A man arrested for statutory rape
d. A man convicted for patronizing prostitution
e. A woman convicted of prostitution
f. A patient whose bodily fluids put an emergency health care worker at risk for HIV

Correct Answer: a. A pregnant woman who has refused in writing.

Feedback: Tennessee Code Annotated Section 39-13-521 (persons arrested or convicted of certain offenses must submit to an HIV test)

Tennessee Code Annotated Section 68-10-117 (health care and emergency workers may request HIV testing of someone whose bodily fluids may have exposed them to HIV)

Tennessee Code Annotated Section 68-5-703 (pregnant women are required to get an HIV test unless they refuse the test in writing).

Number 101. In Tennessee, if a 27 year-old patient comes in with a broken jaw from being hit by her boyfriend's fist, a physician is required to report the case to the appropriate authorities as

a. Spousal abuse
b. Domestic violence
c. An injury inflicted by means of violence
d. No report is required under these circumstances and would be a breach of confidentiality.

Correct Answer: c. An injury inflicted by means of violence

Feedback: Tennessee does not have a specific statute that requires physicians to report suspected cases of domestic violence as it requires the reporting of suspected cases of child and elder abuse. Thus, domestic violence cases must be reported by physicians under a statute that requires a physician to report injuries inflicted by means of a knife, pistol, gun, or other deadly weapon, or by other means of violence. Because the report is required by law, it is not a breach of confidentiality for the physician to make the report. See, Tenn. Code Ann. Section 38-1-101.

Beginning July 1, 2007, health care practitioners are required to file a monthly report with the department of health, office of health statistics, regarding their cases, including suspected cases, of domestic abuse or violence. The report should NOT disclose the name or identify the patient, but should include the nature and extent of the patient's injuries, the substance of any statements made by the patient, including comments concerning past domestic abuse, that would reasonably give rise to suspicion of domestic abuse. The practitioner should include any other information upon which he suspicion of domestic abuse is based. See, Tenn. Code Ann. Section 36-3-621(c).

Number 102. Generally, disclosure of confidential communications between a physician and a patient

a. Cannot be compelled because of the physician-patient privilege.
b. Can be compelled by court order.
c. Cannot be compelled because they are confidential.
d. Can be compelled only if patient signs an authorization.

Correct Answer: b. Can be compelled by court order.

Feedback: Tennessee does not recognize a testimonial privilege for confidential communications between a physician and patient. Thus, a physician may be compelled by court order to testify or produce medical records even though doing so will disclose confidential communications.
See, Alsip v. Johnson City Medical Center, 197 S.W.3d 722 (Tenn. 2006).

Note: A physician is exempt from subpoena to a civil trial in Tennessee state courts, but not exempt from subpoena to a deposition. Tennessee Code Annotated Section 24-9-101.

Number 103. Patient's husband wants to prove that Patient is an unfit mother, so he can get custody of their children. Her psychiatrist receives a subpoena to testify at a deposition. Psychiatrist refuses to testify. How should the court handle this situation?

a. Compel psychiatrist to testify only to the extent that Patient has denied mental health problems.
b. Compel psychiatrist to testify because there is no psychiatrist-patient privilege.
c. Refuse to compel psychiatrist to testify because there is a psychiatrist-patient privilege.
d. Refuse to compel psychiatrist to testify even if the patient signs an authorization waiving the privilege.

Correct Answer: c. Refuse to compel psychiatrist to testify because there is a psychiatrist-patient privilege.

Feedback: Tennessee recognizes a psychiatrist-patient privilege, so the psychiatrist cannot be compelled, even by court order, to testify in this case. There are exceptions to the privilege which would allow a psychiatrist to disclose confidential communications of a patient without the patient's consent. These exceptions are: (1) when the patient raises the issue of his or her mental or emotional condition in a judicial proceeding; (2) when the court orders an assessment of a party by a psychiatrist, (3) in involuntary commitment proceedings; and (4) when the patient makes a credible threat to physically harm an identifiable third party. Tenn. Code Ann. Section 24-1-207.

Tennessee also recognizes a psychologist-patient privilege. Tenn. Code Ann. Section 63-11-213, and a privilege for licensed marital and family therapists, licensed professional counselors, certified clinical pastoral therapists, Code Section 63-22-114, and licensed social workers, Code Section 63-23-109, and licensed psychiatric nurse, Code Section 63-7-125..

Georgia law does not recognize most of these exceptions to the mental health privilege. Only in very, very, limited circumstances may a mental health professional disclose confidential communications. Georgia statute applies the privilege to confidential communications between a patient and a psychiatrist, a licensed psychologist, a licensed clinical social worker, a clinical nurse specialist in mental health or psychiatry, a licensed family and marriage counselor, or a licensed professional counselor. O.C.G.A. Section 24-9-21. Case law in Georgia has also applied the privilege to physicians who devote a substantial portion of their practice to the treatment of mental health problems. See, Wiles v. Wiles, 264 Ga. 594 (1994).

Number 104. Patient confesses to Psychiatrist that he intends to kill his spouse by putting arsenic in her morning coffee. He has purchased the arsenic, and he can't wait to get rid of her. Which of the following represents Psychiatrist's preferred course of action under Tennessee law?

a. Tell wife that Patient has purchased arsenic to put in her morning coffee.
b. Suggest that she cut back on drinking coffee.
c. Send an anonymous letter to the police department.
d. Do nothing. This is confidential information.
e. Initiate involuntary commitment proceedings against Patient.

Correct Answer: a. Tell wife that Patient has purchased arsenic to put in her morning coffee.

Feedback: Under Tennessee law, Psychiatrist may disclose confidential communications without the patient's consent if the patient has made an actual threat to physically harm an identifiable victim, and the psychiatrist makes a clinical judgment that the patient has the apparent capability to commit such an act, and that it is more likely than not that in the near future the patient will carry out the threat. The psychiatrist may disclose confidential communications to the extent necessary to warn or protect any potential victim. Tenn. Code Ann. Sections 24-1-207 and 33-3-206.

Tennessee also gives the psychiatrist the option of initiating voluntary or involuntary commitment proceedings. However, unless patient meets the statutory criteria, this method may not be effective.

Most states follow this rule, which was originally articulated in Tarasoff v. Regents of Univ. of California, 529 P.2d 553 (Cal. 1974), However, Georgia does not clearly recognize the duty to warn, and a psychiatrist or other mental health professional risks breaching a duty of confidentiality by disclosing this type of information. In Georgia, a psychiatrist's preferred option would be to initiate involuntary commitment proceedings. See, Bradley Center v. Wessner, 250 Ga. 199 (1982).

Number 105. Psychiatrist has been appointed by the court to determine whether Patient was legally insane at the time he committed the crime. If Psychiatrist finds that Patient was sane, can Patient get Psychiatrist's testimony excluded from evidence?

a. No, because he waived his right of confidentiality when he raised the insanity defense.
b. Yes, because of the psychiatrist-patient privilege.
c. No, because the psychiatrist-patient privilege does not apply to a court-ordered evaluation.
d. Yes, because the physician-patient relationship creates a duty of confidentiality.

Correct Answer: c. No, because the psychiatrist-patient privilege does not apply to a court-ordered evaluation.

Feedback: Tenn. Code Ann. Section 24-1-207(a)(2).

Number 106. Patient, 66 years old, arrives at the ER with a broken jaw and suspicious bruises. Under Tennessee law, the ER physician is obligated to report the case under

a. Non-accidental injury statute
b. Domestic Violence statute
c. Adult Protection Act
d. Spousal Abuse statute
e. Assault and battery statute

Correct Answer: c. Adult Protection Act

Feedback: Physicians are required by law in Tennessee to report suspected cases of abuse, neglect or exploitation against a disabled adult or an adult of advanced years (60 years old or older) who is unable to care for or protect him or herself. Failure to make a required report is a misdemeanor. Tennessee Adult Protection Act, Tenn. Code Ann. Sections 71-6-101 through 71-6-122.

Number 107. A physician may be charged with which of the following if he or she knowingly and willfully fails to report a suspected case of child abuse.

a. Felony
b. Misdemeanor
c. Civil violation
d. Medical malpractice
e. Tort

Correct Answer: b. Misdemeanor

Feedback: Tenn. Code Ann. Section 37-1-412.

Number 108. Patient is a pregnant 14-year old girl. She tells Physician that the father is her 18-year-old boyfriend. Under Tennessee law, Physician is

a. Not required to report the incident.
b. Encouraged to report the incident as statutory rape after obtaining consent of the patient, her parents or legal guardian.
c. Required to report the incident as child sexual abuse.
d. Required to report the incident as an injury inflicted by means of violence.

Correct Answer: b. Encouraged to report the incident as statutory rape after obtaining consent of the patient, her parents or legal guardian.

Feedback: Under Tennessee law, it is statutory rape because the victim is at least 13 years old but less than 15 years of age, and her sexual partner is at least four years older. Tenn. Code Ann. Section 39-13-506. It is not child sexual abuse because she is older than 13 years old. Tenn. Code Ann. Section 37-1-602.

While Tennessee requires the reporting of child sexual abuse, it merely "encourages" physicians to report statutory rape after determining the minor patient is pregnant by someone who is at least four years older and not her legal spouse, and after obtaining the consent of the patient, her parents or legal guardian. Section 38-1-302. Under Section 38-1-305, public assistance programs are required to report suspected cases of statutory rape upon the mother applying for child support services.

Note: In Tennessee, the definition or degree of statutory rape differs depending upon the age of the victim and the age of the perpetrator.

In Georgia, it is statutory rape, and a physician would be required to report it under the statute that requires physicians to report nonaccidental injuries, i.e., those inflicted by gun, knife, other deadly weapon, etc. It would not be reported as sexual abuse because Georgia law defines "sexual abuse" to exclude consensual sex acts involving persons of the opposite sex when the sex acts are between minors or between a minor and an adult who is not more than five years older than the minor. OCGA Section 16-6-3 (statutory rape).

Number 109. Patient, a 16-year old girl, confides in Physician that her uncle, who has been living with her family, is sexually abusing her. Under Tennessee law, Physician is

a. Required to report it as child abuse
b. Encouraged to report it as statutory rape after obtaining patient's consent
c. Required to report it as child sexual abuse
d. Not required to report it
e. Required to report it as an injury inflicted by means of violence

Correct Answer: c. Required to report it as child sexual abuse

Feedback: Generally, child sexual abuse is defined under Tennessee law as "the commission of any act involving the unlawful sexual abuse, molestation, fondling or carnal knowledge of a child under thirteen (13) years of age . . . " Tennessee Code Annotated Section 37-1-602(3)(B). However, if the abuser is related to the victim, it is child sexual abuse if the victim is between the ages of 13 and 17.

"For the purposes of reporting, investigation, and treatment . . . 'child sexual abuse' also means the commission of any act [defined by law to be a sexual abuse] against a child thirteen (13) years of age through seventeen (17) years of age if such act is committed against the child by a parent, guardian, relative, person residing in the child's home, or other person responsible for the care and custody of the child."
Tennessee Code Annotated Sections 37-1-602 (D). See also, Section 37-1-605.

Number 110. Patient is an elderly lady with cognitive impairments that make her an unsafe driver. Physician believes that she is a threat to herself and to the public safety. According to the AMA's Code of Medical Ethics, what is physician's preferred course of action?

a. Report her to the Department of Motor Vehicles immediately.
b. Encourage her to stop driving and if she ignores this advice, report her impairments to the Department of Motor Vehicles.
c. Encourage her to stop driving and if she ignores this advice, recommend a suspension of her driver's license to the Department of Motor Vehicles.
d. Do nothing without her consent. This information is confidential.

Correct Answer: b. Encourage her to stop driving and if she ignores this advice, report her impairments to the Department of Motor Vehicles.

Feedback: AMA Code of Medical Ethics Section 2.24. Impaired Drivers and Their Physicians. This section states that before a physician considers his or her options with regard to a patient who may be a danger behind the wheel, physicians must be able to identify and document physical or mental impairments that clearly relate to the ability to drive, and the driver must pose a clear risk to the public safety. Before reporting, the physician should discuss the issue with the patient and the patient's family and try to work out an acceptable solution that protects the patient and the driving public, making a report unnecessary. This section goes on to state:

"(3) Physicians should use their best judgment when determining when to report impairments that could limit a patient's ability to drive safely. In situations where clear evidence of substantial driving impairment implies a strong threat to patient and public safety, and where the physician's advice to discontinue driving privileges is ignored, it is desirable and ethical to notify the Department of Motor Vehicles.
"(4) The physician's role is to report medical conditions that would impair safe driving as dictated by his or her state's mandatory reporting laws and standards of medical practice. The determination of the inability to drive safely should be made by the state's Department of Motor Vehicles.
"(5) Physicians should disclose and explain to their patients this responsibility to report.
"(6) Physicians should protect patient confidentiality by ensuring that only the minimal amount of information is reported and that reasonable security measures are used in handling that information."

Tennessee does not have a mandatory reporting law with reference to impaired drivers. In 2003, the legislative assembly considered a bill that would protect health care providers for making a report, but the bill did not become law. Thus, it is possible that a patient could bring a lawsuit against a physician for breaching confidentiality if the physician reports his or her impairments to the Department of Motor Vehicles. On the other hand, there is precedent in Tennessee for a physician to be held liable for injuries inflicted by a patient on a third party.

See, Burroughts v. Magee, 118 S.W.3d 323 (Tenn. 2003) (held physician owed duty to injured third parties to warn his patient of the risks of driving under the influence of two prescribed drugs), and Wharton Transport Corp. v. Bridges, 606 S.W.2d 521 (Tenn. 1980) (held that physician who performed mandatory pre-employment physical examinations of prospective truck drivers owed a duty to the members of a family who were injured by a truck driver the physician had negligently certified as physically qualified to drive).

Number 111. The HIPAA Privacy Rule does not prohibit covered entities from engaging in common and important health care practices as long as reasonable precautions have been taken to protect a patient's privacy. Which of the following practices would violate HIPAA?

a. Displaying patient care signs, such as "high risk fall," on hospital room doors without identifying information visible.
b. Identifying the purpose of the patient's visit on patient sign-in sheets.
c. Placing patient charts outside of exam rooms with identifying information facing the wall.
d. Using in-patient logs, such as a whiteboard, at a nursing station where it is not readily visible to the public.
e. Angling computer screens with patient information away from public view.

Correct Answer: b. Identifying the purpose of the patient's visit on patient sign-in sheets.

Feedback: 45 CFR 164.502(a)(1)(iii).

Number 112. HIPAA does not prohibit health care providers from talking to each other and their patients even if they may be overheard as long as reasonable safeguards are taken. Which of the following is a violation of HIPAA's Privacy Rule.

a. Discussing lab test results with a patient or other provider in a joint treatment area.
b. Discussing a patient's condition or treatment regimen in the patient's semi-private room.
c. Discussing a patient by name in a crowded elevator with another treating physician.
d. Discussing a patient's condition during training rounds in an academic or training institution.
e. Discussing a patient's condition over the phone with the patient, a provider, or a family member.

Correct Answer: c. Discussing a patient by name in a crowded elevator with another treating physician.

Feedback: HHS Frequent Questions: Can health care providers engage in confidential conversations with other providers or with patients, even if there is a possibility that they could be overheard? Yes. http://www.hhs.gov/hipaafaq/limited/196.html. Accessed November 21, 2007.

Number 113. Under the HIPAA Privacy Rule, the minimum necessary standard does not apply to which of the following?

a. Disclosures for treatment purposes.
b. Disclosures for payment purposes.
c. Disclosures for health care operation purposes.
d. Disclosures for marketing purposes.

Correct Answer: a. Disclosures for treatment purposes.

Feedback: 45 CFR 164.502(b), 164.514(d).

Number 114. In addition to HIPAA, physicians also must be aware of state law that protects patient privacy. Unless HIPAA defers to state law, HIPAA takes priority, except in the following situation.

a. When state law is contrary to HIPAA, and no exemption is obtained.
b. When state law protects a patient's privacy more stringently than HIPAA.
c. When state law existed prior to the enactment of HIPAA.
d. When state law specifically states that it takes precedence over HIPAA.

Correct Answer: b. When state law protects a patient's privacy more stringently than HIPAA.

Feedback: HHS FAQ: Does the HIPAA Privacy Rule preempt State law? http://www.hhs.gov/hipaafaq/state/399.html. Accessed November 21, 2007.

Number 115. The HIPAA Privacy Rule creates national standards to protect individuals' medical records and other personal health information. Which of the following is not a purpose or goal of HIPAA's Privacy Rule?

a. To give patients more control over their health information.
b. To set boundaries on the use and release of health records.
c. To hold violators accountable, with civil and criminal penalties that can be imposed, if they violate patients' privacy rights.
d. To give patients ownership of their medical records.

Correct Answer: d. To give patients ownership of their medical records.

Feedback: Ownership of medical records belongs to the physician or medical facility. A patient has the right to review his or her records, as well as the right to receive copies. A patient may request to review the original records, but a patient should not be given the original records unsupervised. See, Tenn. Code Ann. Section 68-11-308.

Number 116. Any person or entity that furnishes, bills or is paid for health care in the normal course of business. The term includes persons (such as dentists, doctors, and psychotherapists), entities, (such as hospitals and clinics), alternative care providers (such as homeopaths and acupuncturists), and the providers of health supplies (such as pharmacists).

Correct Answer: Health Care Provider

Number 117. A "health care provider" is defined as any person or entity that furnishes, bills or is paid for health care in the normal course of business. The term includes persons (such as dentists, doctors, and psychotherapists), entities, (such as hospitals and clinics), alternative care providers (such as homeopaths and acupuncturists), and the providers of health supplies (such as pharmacists).

Number 118. Any oral or recorded information relating to the past, present or future physical or mental health of an individual, including the provision of health care to the individual, or the payment for health care. The term not only covers traditional medical records but also a doctor's personal notes and billing information.

Correct Answer: Health Information

Number 119. "Health information" is defined as any oral or recorded information relating to the past, present or future physical or mental health of an individual, including the provision of health care to the individual, or the payment for health care. The term not only covers traditional medical records but also a doctor's personal notes and billing information.

Number 120. Certain administrative, financial, legal, and quality improvement activities of a covered entity that are necessary to run its business and to support core functions of treatment and payment. Includes quality assessment and improvement activities, case management and care coordination, reviewing the competence or qualifications of health care professionals, training, customer service, underwriting, arranging for legal services, business planning, resolution of internal grievances, fundraising, etc.

Correct Answer: Health Care Operations

Number 121. "Health care operations are defined as certain administrative, financial, legal, and quality improvement activities of a covered entity that are necessary to run its business and to support core functions of treatment and payment. Includes quality assessment and improvement activities, case management and care coordination, reviewing the competence or qualifications of health care professionals, training, customer service, underwriting, arranging for legal services, business planning, resolution of internal grievances, fundraising, etc.

Number 122. Any individual or group plan that provides or pays for medical care. The term includes both private and governmental plans.

Correct Answer: Health Plan

Number 123. A "health plan" is defined as any individual or group plan that provides or pays for medical care. The term includes both private and governmental plans.

Number 124. Health information that identifies or reasonably can be used to identify an individual person.

Correct Answer: Individually Identifiable Health Information

Number 125. "Individually identifiable health information" is defined as health information that identifies or reasonably can be used to identify an individual person.

Number 126. An arrangement between a covered entity and any other entity whereby the covered entity discloses protected health information to the other entity, in exchange for direct or indirect remuneration, for the other entity or its affiliate to make a communication about its own product or service that encourages the recipient of the communication to purchase or use the product or service.

Correct Answer: Marketing

Number 127. "Marketing" is defined as an arrangement between a covered entity and any other entity whereby the covered entity discloses protected health information to the other entity, in exchange for direct or indirect remuneration, for the other entity or its affiliate to make a communication about its own product or service that encourages the recipient of the communication to purchase or use the product or service.

Number 128. The provision, coordination, or management of health care, including consultations and referrals between health care providers.

Correct Answer: Treatment

Number 129. "Treatment" is defined as the provision, coordination, or management of health care, including consultations and referrals between health care providers.

Number 130. Occurs as a by-product of another permissible or required use or disclosure, as long as the covered entity has applied reasonable safeguards and implemented the minimum necessary standard, where applicable, with respect to the primary use or disclosure.

Correct Answer: Incidental Use and Disclosure

Number 131. "Incidental use and disclosure " occurs as a by-product of another permissible or required use or disclosure, as long as the covered entity has applied reasonable safeguards and implemented the minimum necessary standard, where applicable, with respect to the primary use or disclosure.

Number 132. Limits how much protected health information is used, disclosed, and requested for certain purposes. Must also reasonably limit who within the entity has access to protected health information, and under what conditions, based on job responsibilities and the nature of the business.

Correct Answer: Minimum Necessary Standard

Number 133. The "minimum necessary standard" limits how much protected health information is used, disclosed, and requested for certain purposes. Must also reasonably limit who within the entity has access to protected health information, and under what conditions, based on job responsibilities and the nature of the business.

Number 134. The minimum necessary standard applies to which one of the following situations?

a. Disclosures or requests by a health care provider for treatment purposes
b. Uses or disclosures that are required by other law.
c. Disclosures to the individual who is the subject of the information
d. Uses or disclosures made pursuant to the individual's authorization
e. Access to a patient's medical records by hospital employees who have no need of the information to do their jobs

Correct Answer: e. Access to a patient's medical records by hospital employees who have no need of the information to do their jobs

Feedback: 45 CFR 164.502(b) and 164.514(d).

Number 135. Includes the various activities of health care providers to obtain reimbursement for their services and of a health plan to obtain premiums, to fulfill their coverage responsibilities and provide benefits under the plan, and to obtain or provide reimbursement for the provision of health care.

Correct Answer: Payment

Number 136. "Payment" includes the various activities of health care providers to obtain reimbursement for their services and of a health plan to obtain premiums, to fulfill their coverage responsibilities and provide benefits under the plan, and to obtain or provide reimbursement for the provision of health care.

Number 137. Health plans; Health care clearinghouses; Prescription drug card sponsors; and Health care providers who conduct certain financial and administrative functions electronically

Correct Answer: Covered Entities

Number 138. "Covered entities" are defined as health plans; health care clearinghouses; prescription drug card sponsors; and health care providers who conduct certain financial and administrative functions electronically

Number 139. A public or private entity, including a billing service, repricing company, community health management information system and value-added networks and switches, that either processes or facilitates the processing of health information.

Correct Answer: Health Care Clearinghouse

Number 140. A "health care clearinghouse" is defined as a public or private entity, including a billing service, repricing company, community health management information system and value-added networks and switches, that either processes or facilitates the processing of health information.

Number 141. What the covered entity must have before using or disclosing a patient's private health information for a non-permissible purpose.

a. Written consent
b. Written authorization
c. Written waiver
d. Written permission

Correct Answer: b. Written authorization

Feedback: HHS FAQ: What is the difference between "consent" and "authorization" under HIPAA Privacy Rule? http://www.hhs.gov/hipaafaq/use/264.html. Accessed November 21, 2007.

Number 142. Uses or disclosures of private health information that do not require a patient's written authorization. Includes uses and disclosures for treatment purposes, for payment purposes, or for health care operations.

Correct Answer: Permissible Use

Number 143. A "permissible use" is defined as uses or disclosures of private health information that do not require a patient's written authorization. Includes uses and disclosures for treatment purposes, for payment purposes, or for health care operations.

Number 144. Limits how much protected health information is used, disclosed, and requested for certain purposes.

a. Incidental use and disclosure
b. Permissible use and disclosure
c. Minimum necessary standard
d. Limited use and disclosure
e. Necessary restrictions

Correct Answer: c. Minimum necessary standard

Feedback: 45 CFR 164.502(b) and 164.514(d).

Number 145. Raw data from psychological and neuropsychological tests, radiological films and images, videotapes, and monitoring strips.

Correct Answer: Source Data

Number 146. "Source data" is defined as the raw data from psychological and neuropsychological tests, radiological films and images, videotapes, and monitoring strips.

Number 147. A use or disclosure of private health information that does not require a patient's written authorization. Includes uses and disclosures for treatment purposes, for payment purposes, or for health care operations.

a. Incidental use and disclosure
b. Minimum necessary standard
c. Limited use and disclosure
d. Permissible use
e. Necessary restrictions

Correct Answer: d. Permissible use

Feedback: 45 CFR 164.506.

Number 148. Medical and billing records about an individual maintained by or for a covered health care provider that are used, in whole or in part, by or for the covered entity to make decisions about an individual.

a. Source Data
b. Permissible Use and Disclosure Log
c. Minimum Necessary Standard Log
d. Incidental Use and Disclosure Log
e. Designated record set

Correct Answer: e. Designated record set

Feedback: 45 CFR Section 164.501.

Number 149. A group of records that contain protected health information and that are used to make decisions about the patient. The patient's right of access is limited to this group of records.

Correct Answer: Designated Record Set

Number 150. The designated record set is a a group of records that contain protected health information and that are used to make decisions about the patient. The patient's right of access is limited to this group of records.

Number 151. In 2004, Tennessee created a new document that can be signed instead of a living will. What is the name of this new document?

a. Right to Die a Natural Death form
b. Do Not Interfere form
c. Advance Care Plan
d. Patient Self-Determination form
e. Patient Autonomy form

Correct Answer: c. Advance Care Plan

Feedback: Tennessee Health Care Decisions Act, Tenn. Code Ann. Section 68-11-1701, et seq. Living wills that are written under the laws existing before 2004 are still effective. A living will that is signed after July 1, 2004 (the effective date), and specifically states that the former law applies will be interpreted under that law. If a living will is signed on or after July 1, 2004 and is silent as to which law applies, the document will be treated as an advance directive under the new law.

Number 152. In 2004, Tennessee created a new document that can be signed instead of a living will. What is the name of this new document?

Correct Answer: Advance Care Plan

Number 153. In 2004, Tennessee created a new document called an Advance Care Plan that can be signed instead of a living will.

Number 154. Acknowledging a patient's right to refuse life-sustaining treatment is most accurately described as:

a. Helping the patient die
b. Making the patient die
c. Prolonging the patient's death
d. Letting the patient die

Correct Answer: d. Letting the patient die

Feedback: A living will or Advance Care Plan expresses a patient's wish to die naturally. The withholding or withdrawal of medical care from a patient in accordance with these laws does not constitute a suicide, euthanasia or homicide. Tenn. Code Ann. Section 32-11-110(a).

Number 155. Which of the following is of the least concern when a physician must decide whether to increase pain medication for a terminally ill patient, and the increase in dosage may hasten the patient's death.

a. The patient may become addicted.
b. Increasing the dosage may be misinterpreted as euthanasia.
c. Failure to increase the dosage may violate the ethical principle to act in the patient's best interest.
d. Failure to manage the patient's pain may result in a medical malpractice lawsuit.
e. Increasing the dosage may open the physician to criminal charges of over-prescription of opiates.
f. Increasing the dosage so that it hastens death may violate the ethical principle of "do no harm."

Correct Answer: a. The patient may become addicted.

Feedback: Physicians are expected to manage their patients' pain, and several large verdicts have been awarded to patients or their families when the physician has failed to do so. Bergman v. Wing Chin and Eden Medical Center (Cal. App. Dept. Super. Ct. 1999), and Estate of Henry James v. Hillhaven Corp. (N.C. Superior Ct. 1991).

However, a number of physicians have been prosecuted for murder or manslaughter when they hastened a patient's death by over-prescription of opiates. See, State v. Naramore, 965 P.2d 211 (Kan. App. 1998).

To avoid either extreme, physicians should be familiar with appropriate protocols for pain management, and they should document in the record how the appropriate protocol was followed for each patient. The AMA Code of Medical Ethics, Section 2.211 discourages physician participation in suicide and maintains that "patients near the end of life must continue to receive emotional support, comfort care, adequate pain control, respect for patient autonomy, and good communication."

Number 156. Choose the most appropriate description of a living will.

a. A laundry list of do's and don'ts for medical treatment.
b. A document that designates who will inherit the patient's property if the patient goes into a nursing home.
c. A patient's statement that he or she wants to die a natural death that is not artificially prolonged.
d. A document that appoints a surrogate decision-maker.

Correct Answer: c. A patient's statement that he or she wants to die a natural death that is not artificially prolonged.

Feedback: Tenn. Code Ann. Section 32-11-103(4). Under the law that became effective in Tennessee on July 1, 2004, a patient may use an Advance Care Plan as a living will and as a means of designating a health care agent. See, Tennessee Health Care Decisions Act, Tenn. Code Ann. Sections 68-11-1701, et seq.

Number 157. Choose the most appropriate description of a durable power of attorney for health care.

a. A patient's statement of a desire to die a natural death.
b. A document that appoints an agent to make health care decisions.
c. A laundry list of do's and don'ts for medical treatment.
d. A document that appoints an agent to handle the patient's finances.

Correct Answer: b. A document that appoints an agent to make health care decisions.

Feedback: Tenn. Code Ann. Section 68-11-1702(14). Under the law that became effective in Tennessee on July 1, 2004, there are several additional documents that a patient may use to designate a health care agent. See, Tennessee Health Care Decisions Act, Tenn. Code Ann. Section 68-11-1701 et seq.

Number 158. Patient is in the hospital and she decides to revoke her living will that she signed on April 5, 1999. For the revocation to be effective, Patient must do what?

a. Tear up her living will.
b. Write her reasons for revoking her living will and put the writing in her pocket.
c. Tell everyone in her family.
d. Communicate the revocation to her attending physician or other concerned health care provider.

Correct Answer: d. Communicate the revocation to her attending physician or other concerned health care provider.

Feedback: Tenn. Code Ann. 32-11-106. "A declaration may be revoked at any time by the declarant, without regard to the declarant's mental state or competency, by any of the following methods, effectively communicated by the declarant to the attending physician or other concerned health care provider: (1) Written revocation by the declarant, dated and signed by the declarant; or (2) by oral statement or revocation made by the declarant to the attending physician. This revocation shall be made a part of the declarant's medical record."

Number 159. Patient is terminally ill and has slipped into an irreversible coma. He is on life support. He has a living will that he signed in 2001 that follows Tennessee's statutory form. In 2005, he designated his brother as his agent in a durable power of attorney for health care. Who gives consent for the termination of life support systems?

a. The attending physician, with the concurrence of a second doctor, based upon the patient's living will.
b. The patient's family, by majority vote.
c. The health care agent, but he is bound by the wishes of the patient as set forth in the living will.
d. The patient's spouse.

Correct Answer: c. The health care agent, but he is bound by the wishes of the patient as set forth in the living will.

Feedback: Under Tennessee law, the patient's health care agent has the right to make patient's health care decisions if patient lacks capacity to make them himself. However, the health care agent must make the decision based upon any written declarations of the patient, which in this case is a living will. See, Tenn. Code Ann. Section 68-11-1703(e).

Note: The living will is interpreted under the pre-2004 legislation. The durable power of attorney for health care is interpreted under the law that became effective on July 1, 2004 unless it specifically states that it should be interpreted under the pre-2004 legislation.

Other states may have different rules, and physicians moving from one state to another must learn the new state's laws. For example, in Georgia, if a patient has both a living will and a durable power of attorney for health care, the living will is ineffective and inoperable as long as the health care agent is available, the two documents are not inconsistent in regards to terminating life support, and the durable power of attorney does not indicate that the living will takes precedence. If these conditions are met, the physician should get the consent of the health care agent before terminating life support despite the existence of a living will. See, O.C.G.A. Section 31-32-11.

Number 160. Patient's Advance Care Plan indicates that he does not want CPR. Patient is in a car accident and comes into the ER and goes into cardiac arrest. Should the ER physician initiate CPR?

a. Yes, if it meets the standard of care to do so.
b. No, because it would be medical battery.
c. No, because it would violate Patient's constitutional right to refuse medical treatment.
d. Yes, because it is an emergency situation.

Correct Answer: a. Yes, if it meets the standard of care to do so.

Feedback: Under Tennessee's Advance Care Plan, a patient may choose whether to accept or refuse certain kinds of treatment. However, the choices are conditioned on the patient's quality of life becoming unacceptable and the condition is irreversible. In this scenario, it is too soon to tell whether these conditions have been met.

The fact that it is an emergency does not necessarily justify rendering medical treatment. An emergency does not obviate a previously stated informed refusal. However, if in doubt, err on the side of life.

For copies of an Advance Care Plan form, see http://health.state.tn.us/Boards/Advance Directives/index.htm

Number 161. Also known as comfort care, it is primarily directed at providing relief to a terminally-ill person through symptom management and pain management. The goal is not to cure, but to provide comfort and maintain the highest possible quality of life for as long as life remains. Such measures include, but are not limited to, sedatives and painkilling drugs, nonartificial oral feeding, suction, hydration and hygienic care.

Correct Answer: Palliative Care

Number 162. "Palliative care" is also known as comfort care. It is primarily directed at providing relief to a terminally-ill person through symptom management and pain management. The goal is not to cure, but to provide comfort and maintain the highest possible quality of life for as long as life remains. Such measures include, but are not limited to, sedatives and painkilling drugs, nonartificial oral feeding, suction, hydration and hygienic care.

Number 163. An order issued by a physician that tells medical personnel not to initiate CPR in the event of cardiopulmonary arrest.

Correct Answer: DNR Order

Number 164. A "DNR order" is an order issued by a physician that tells medical personnel not to initiate CPR in the event of cardiopulmonary arrest.

Number 165. POST

Correct Answer: Physician Orders for Scope of Treatment

Number 166. "POST" stands for "Physician Orders for Scope of Treatment." It is a physician order sheet based upon the medical condition and wishes of the patient.

Number 167. A written declaration that the patient wants to die a natural death and that dying not be prolonged artificially. This document authorizes that life-sustaining measures may be withheld or withdrawn if the attending physician diagnoses that the patient is in a terminal condition and determines that there is no reasonable medical expectation of recovery. Under Tennessee law, this document may also address organ and tissue donation.

Correct Answer: Living Will

Number 168. A "living will" is a written declaration that the patient wants to die a natural death and that dying not be prolonged artificially. This document authorizes that life-sustaining measures may be withheld or withdrawn if the attending physician diagnoses that the patient is in a terminal condition and determines that there is no reasonable medical expectation of recovery. Under Tennessee law, this document may also address organ and tissue donation.

Number 169. When a physician provides the means for a patient to terminate his or her life.

Correct Answer: Physician-Assisted Suicide

Number 170. "Physician-assisted suicide" occurs when a physician provides the means for a patient to terminate his or her life.

Number 171. An act by a physician that intentionally hastens a patient's death.

Correct Answer: Euthanasia

Number 172. "Euthanasia" is an act by a physician that intentionally hastens a patient's death.

Number 173. A document that delegates the authority to make health care decisions to an attorney-in-fact (now called a health care agent).

Correct Answer: Durable Power of Attorney for Health Care

Number 174. A "durable power of attorney for health care" is a document that delegates the authority to make health care decisions to an attorney-in-fact (now called a health care agent).

Number 175. Any disease, illness, injury, or condition, including but not limited to, a coma or persistent vegetative state, sustained by any human being, from which there is no reasonable medical expectation of recovery and that, as a medical probability, will result in the death of the human being, regardless of the use or discontinuance of medical treatment implemented for the purpose of sustaining life, or the life processes.

Correct Answer: Terminal Condition

Number 176. A "terminal condition" means any disease, illness, injury, or condition, including but not limited to, a coma or persistent vegetative state, sustained by any human being, from which there is no reasonable medical expectation of recovery and that, as a medical probability, will result in the death of the human being, regardless of the use or discontinuance of medical treatment implemented for the purpose of sustaining life, or the life processes.

Number 177. Legal description of a patient after a determination is made in accordance with acceptable medical standards that the patient has sustained either (1) irreversible cessation of circulatory and respiratory functions, or (2) irreversible cessation of all functions of the entire brain, including the brain stem.

Correct Answer: Dead

Number 178. "Dead" is the legal description of a patient after a determination is made in accordance with acceptable medical standards that the patient has sustained either (1) irreversible cessation of circulatory and respiratory functions, or (2) irreversible cessation of all functions of the entire brain, including the brain stem.

Number 179. Patient is terminally ill, and Physician determines that she lacks capacity to make her health care decisions. She has not designated a health care agent or surrogate, nor has a court appointed a guardian to make her health care decisions. After considering the appropriate criteria, Physician designates her oldest son as her surrogate. They must decide whether to initiate artificial nutrition and hydration. Physician recommends withholding artificial nutrition and hydration because it would only prolong the act of dying. Who has the right to refuse artificial nutrition and hydration on Patient's behalf?

a. Her spouse
b. Her family members by majority vote
c. Her son, but only with the appropriate certification of Physician and an second independent physician
d. Her son has the sole right to make this decision
e. Her physician

Correct Answer: c. Her son, but only with the appropriate certification of Physician and an second independent physician

Feedback: Tenn. Code Ann. Section 68-11-1706(e): "A surrogate who has not been designated by the patient may make all health care decisions for the patient that the patient could make on the patient's own behalf, except that artificial nutrition and hydration may be withheld or withdrawn for a patient upon a decision of the surrogate only when the designated physician and a second independent physician certify in the patient's current clinical records that the provision or continuation of artificial nutrition or hydration is merely prolonging the act of dying and the patient is highly unlikely to regain capacity to make medical decisions."

Number 180. With an Advance Care Plan, a patient may do which of the following?

a. Provide other instructions, such as for hospice care, burial, etc.
b. Accept or reject medical treatment under specified conditions
c. Designate a health care agent
d. Donate organs
e. All of these.

Correct Answer: e. All of these.

Feedback: Tenn. Code Ann. Sections 68-11-1701 et seq. For a copy of an Advance Care Plan, see http://health.state.tn.us/Boards/AdvanceDirectives/index.htm

Number 181. If a patient has a living will, the physician should enter a do not resuscitate order.

a. True
b. False

Correct Answer: b. False

Feedback: A living will is not the equivalent of a do not resuscitate order (DNR). The two documents are not interchangeable. A living will expresses the patient's wishes while a DNR order is a physician's order directing medical personnel not to initiate CPR if the patient stops breathing or if his or her heart stops beating. A physician must determine whether certain conditions are met before honoring a patient's living will. If the conditions are met, then a physician may determine to enter a DNR order with the consent of the patient or someone legally authorized to make such a decision. Just because someone has a living will does not mean it is appropriate to enter an DNR order.

Number 182. Patient is in the final stages of cancer, but he still has the capacity to make his medical decisions. He and his doctor discuss at length how he wants his medical care handled. Under Tennessee law, what is the preferred method for doctor to record the results of their discussion in patient's chart?

a. MOST
b. POST
c. HOST
d. CARE

Correct Answer: b. POST

Feedback: POST stands for "Physician Orders for Scope of Treatment." This is a physician's order sheet based on the medical conditions and wishes of the patient. For a copy of a POST form see, http://health.state.tn.us/Boards/AdvanceDirectives/index.htm

Number 183. Patient is an elderly widow whose relatives include two adult children and a brother. Her children do not live close, and they visit every other Christmas. She has been estranged from her brother for 20 years. Patient is very ill and lacks the capacity to make her health care decisions. Her neighbor and best friend brought her to the ER and has been a constant visitor at the hospital. Patient's children and brother arrive two days after Patient was admitted. Patient did not designate a health care agent or surrogate, and a court has not appointed a guardian. Based on these facts, who is the most appropriate choice for the physician-designated surrogate under Tennessee law?

a. Oldest child
b. Both children
c. Brother
d. Neighbor
e. Her physician

Correct Answer: d. Neighbor

Feedback: Tenn. Code Ann. Section 68-11-1706(c): "(1) In the case of a patient who lacks capacity, has not appointed an agent, has not designated a surrogate, and does not have a guardian, or whose agent, surrogate, or guardian is not reasonably available, the patient's surrogate shall be identified by the supervising health care provider and documented in the current clinical record of the institution or institutions at which the patient is then receiving health care."

"(2) The patient's surrogate shall be an adult who has exhibited special care and concern for the patient, who is familiar with the patient's personal values, who is reasonably available, and who is willing to serve. . . . "

"(3) Consideration may be given in order of descending preference for service as a surrogate to: (A) the patient's spouse, unless legally separated; (B) the patient's adult child; (C) the patient's parent; (D) the patient's adult sibling; (E) any other adult relative of the patient; or (F) any other adult who satisfies the requirements of subdivision (c)(2) of this section."

"(4) The following criteria shall be considered in the determination of the person best qualified to serve as the surrogate: (A) Whether the proposed surrogate reasonably appears to be better able to make decisions either in accordance with the known wishes of the patient or in accordance with the patient's best interests; (B) The proposed surrogate's regular contact with the patient prior to and during the incapacitating illness; (C) The proposed surrogates's demonstrated care and concern; (E) The proposed surrogate's availability to engage in face-to-face contact with health care providers for the purpose of fully participating in the decision-making process."

Number 184. The designated physician or, if there is no designated physician or the designated physician is not reasonably available, the health care provider who has undertaken primary responsibility for an individual's health care.

Correct Answer: Supervising health care provider

Number 185. "Supervising health care provider" means the designated physician or, if there is no designated physician or the designated physician is not reasonably available, the health care provider who has undertaken primary responsibility for an individual's health care.

Number 186. An act by a physician that intentionally hastens a patient's death.

a. Physician-assisted suicide
b. Palliative care
c. Euthanasia
d. Double Effect

Correct Answer: c. Euthanasia

Feedback: Currently, euthanasia is illegal in all 50 states.

Number 187. A theory used to justify administering medication that will hasten the patient's death when the main purpose of the medication is to relieve pain.

Correct Answer: Double Effect

Number 188. "Double effect" is a theory used to justify administering medication that will hasten the patient's death when the main purpose of the medication is to relieve pain.

Number 189. A theory used to justify administering medication that will hasten a patient's death when the main purpose of the medication is to relieve pain.

a. Palliative care
b. Res ipsa loquitur
c. Primary purpose
d. Double effect

Correct Answer: d. Double effect

Feedback: "Double effect" is only a theory used to justify administering medication that will hasten a patient's death when the main purpose of the medication is to relieve pain. It is not an absolute defense, and it should not be relied upon to insulate a physician from prosecution. To avoid charges of murder or manslaughter, physicians should be familiar with pain management protocols and document how they were followed for each patient.

Number 190. Legal description of a patient after a determination has been made in accordance with accepted medical standards that the patient has sustained either (1) irreversible cessation of circulatory and respiratory function, or (2) irreversible cessation of all functions of the entire brain, including the brain stem.

a. Comatose
b. Persistent vegetative state
c. Dead
d. Cognitively impaired

Correct Answer: c. Dead

Feedback: Uniform Determination of Death Act, Tenn. Code Ann. Section 68-3-501.

Number 191. An individual instruction or a written statement relating to the subsequent provision of health care for the individual, including, but not limited to a living will or a durable power of attorney for health care.

Correct Answer: Advance Directive

Number 192. An advance directive is an individual instruction or a written statement relating to the subsequent provision of health care for the individual, including, but not limited to a living will or a durable power of attorney for health care.

Number 193. An individual's ability to understand the significant benefits, risks, and alternatives to proposed health care and to make and communicate a health care decision.

Correct Answer: Capacity

Number 194. "Capacity" means an individual's ability to understand the significant benefits, risks, and alternatives to proposed health care and to make and communicate a health care decision.

Number 195. A physician designated by an individual or the individual's agent, guardian, or surrogate, to have primary responsibility for the individual's health care or, in the absence of a designation or if the designated physician is not reasonably available, a physician who undertakes such responsibility.

Correct Answer: Designated Physician

Number 196. A "designated physician" is a physician designated by an individual or the individual's agent, guardian, or surrogate, to have primary responsibility for the individual's health care or, in the absence of a designation or if the designated physician is not reasonably available, a physician who undertakes such responsibility.

Number 197. A judicially appointed guardian or conservator having authority to make a health care decision for an individual.

Correct Answer: Guardian

Number 198. A "guardian" is a judicially appointed guardian or conservator having authority to make a health care decision for an individual.

Number 199. Consent, refusal of consent, or withdrawal of consent to health care.

Correct Answer: Health Care Decision

Number 200. "Health care decision" means consent, refusal of consent, or withdrawal of consent to health care.

Number 201. Readily able to be contacted without undue effort and willing and able to act in a timely manner considering the urgency of the patient's health care needs. Such availability shall include, but not be limited to, availability by telephone.

Correct Answer: Reasonably Available

Number 202. "Reasonably available" means readily able to be contacted without undue effort and willing and able to act in a timely manner considering the urgency of the patient's health care needs. Such availability shall include, but not be limited to, availability by telephone.

Number 203. An individual, other than a patient's agent or guardian, authorized to make health care decisions for the patient.

Correct Answer: Surrogate

Number 204. "Surrogate" means an individual, other than a patient's agent or guardian, authorized to make health care decisions for the patient.

Number 205. An individual designated in an advance directive for health care to make health care decisions for the individual granting the power when the individual lacks capacity to make his or her own health care decisions.

Correct Answer: Health Care Agent

Number 206. A "health care agent" is an individual designated in an advance directive for health care to make health care decisions for the individual granting the power when the individual lacks capacity to make his or her own health care decisions.

Number 207. A health care agent's or surrogate's power to make health care decisions on behalf of the patient begins upon the happening of what event?

a. Immediately upon the patient's signing the appropriate document.
b. The designated physician determines that the patient lacks capacity.
c. After a court has determined that patient is not legally competent.
d. After a psychiatric evaluation has determined that patient lacks capacity.

Correct Answer: b. The designated physician determines that the patient lacks capacity.

Feedback: Tenn. Code Ann. Sections 68-11-1703(c) and (d) and 68-11-1706(b). In making such determination, the designated physician is authorized to consult with such other persons as he or she may deem appropriate. A psychiatric consult may be helpful in this determination, but it is not necessary under the law. However, if there is a question about patient's capacity in a subsequent legal proceeding, a psychiatric consult may be persuasive evidence.

Number 208. Patient is in the hospital in the final stages of cancer. He tells his physician that he does not want to be resuscitated if his heart stops beating or if he stops breathing. He is scheduled to be transferred to another facility in several days. What is his physician's preferred course of action in handling his request that he not receive CPR?

a. Write patient's preferences in his medical chart
b. Enter a Do Not Resuscitate Order for the current facility
c. Enter a Do Not Resuscitate Order for the facility where he will be transferred
d. Enter a Universal Do Not Resuscitate Order
e. Put a large sign on his hospital door that says "STOP".

Correct Answer: d. Enter a Universal Do Not Resuscitate Order

Feedback: A copy of a Universal Do Not Resuscitate Order (UDNR order) must accompany the patient to the new facility upon transfer, and the new facility must make it part of his medical record. A UDNR order may also be part of a POST (Physician Orders for Scope of Treatment). The UDNR order became available in Tennessee in 2004 with passage of the Tennessee Health Care Decisions Act, eliminating the problem that a DNR order was only valid in the medical facility issuing it. Tennessee Code Annotated, Section 68-11-224.

Number 209. Patient signs a living will on May 4, 2006 in Tennessee. No mention is made of what law should apply to the interpretation of the document. Under what law should Patient's living will be interpreted?

a. Tennessee Right to a Natural Death Act
b. Tennessee Health Care Decisions Act
c. Tennessee Anatomical Gift Act
d. Tennessee Uniform Determination of Death Act

Correct Answer: b. Tennessee Health Care Decisions Act

Feedback: Tennessee Code Annotated, Section 32-11-113. Although a living will was created under the Tennessee Right to a Natural Death Act, passed in the mid-80s, because this living will was signed on or after July 1, 2004, and because it does not specify that it will be interpreted under the Tennessee Natural Death Act, it will be interpreted under the Tennessee Health Care Decisions Act that became effective July 1, 2004. Exactly how this will work is unclear, and physicians may need to seek legal counsel if a question arises under a living will signed on or after July 1, 2004 and that does not specify it is to be interpreted under the Right to a Natural Death Act.

Number 210. Physician-assisted suicide is legal

a. In all 50 states
b. In Oregon, Washington, and Montana
c. Only in Oregon
d. Only in California
e. In about one fourth of the states

Correct Answer: b. In Oregon, Washington, and Montana

Number 211. A civil wrong. It can be intentional or negligent.

Correct Answer: Tort

Number 212. A "tort" is defined as a civil wrong. It can be intentional or negligent.

Number 213. The legal term for when a health care professional owes a duty to a patient, breaches that duty, and the patient suffers damages that are proximately caused by the breach of duty.

Correct Answer: Malpractice

Number 214. "Malpractice" is the legal term for when a health care professional owes a duty to a patient, breaches that duty, and the patient suffers damages that are proximately caused by the breach of duty.

Number 215. Information on all licensed physicians is posted on the Web site of the Tennessee Board of Medical Examiners. It includes information on medical malpractice judgments and settlements. http://health.state.tn.us/Boards/ME/index.htm

Correct Answer: Physician Profile Data

Number 216. Physician profile data is listed on the Web site of the Tennessee Board of Medical Examiners. It contains information on all licensed physicians, including information on medical malpractice judgments and settlements. http://health.state.tn.us/Boards/ME/index.htm

Number 217. A person who stands in a position of trust.

Correct Answer: Fiduciary

Number 218. A "fiduciary" is a person who stands in a position of trust.

Number 219. The amount of claims paid out compared to the amount of premiums collected by an insurance company.

Correct Answer: Loss Ratio

Number 220. "Loss ratio" is the amount of claims paid out compared to the amount of premiums collected by an insurance company.

Number 221. Federal agency that issued a report in June 2003 that concluded multiple factors have contributed to the medical malpractice crisis, but that "losses on medical malpractice claims, which make up the largest part of insurers' cost appear to be the primary driver of rate increases in the long run."

Correct Answer: GAO (General Accounting Office)

Number 222. The GAO (General Accounting Office) is a federal agency that issued a report in June 2003 that concluded multiple factors have contributed to the medical malpractice crisis, but that "losses on medical malpractice claims, which make up the largest part of insurers' cost appear to be the primary driver of rate increases in the long run."

Number 223. Identifying potential problems, eliminating or minimizing the identified problems, buying insurance to cover the problems that cannot be eliminated, and minimizing potential exposure to liability.

Correct Answer: Risk Management

Number 224. Someone who engages in risk management identifies potential problems, eliminates or minimizes the identified problems, buys insurance to cover the problems that cannot be eliminated, and minimizes potential exposure to liability.

Number 225. Any event not consistent with the normal and routine operation of the health system.

Correct Answer: Variant Event

Number 226. A "variant event" is any event not consistent with the normal and routine operation of the health system.

Number 227. A patient care event that is an unexpected occurrence involving death or serious physical or psychological injury or the risk thereof.

Correct Answer: Sentinel Event

Number 228. A "sentinel event" is a patient care event that is an unexpected occurrence involving death or serious physical or psychological injury or the risk thereof.

Number 229. A critical element in the physician-patient relationship that helps avoid medical malpractice lawsuits.

Correct Answer: Communication

Number 230. Communication is a critical element in the physician-patient relationship that helps avoid medical malpractice lawsuits.

Number 231. Changes in the law designed to bring about a reduction in the number of frivolous medical malpractice lawsuits that are filed and to limit inflated jury awards.

Correct Answer: Tort Reform

Number 232. Tort reform changes the law to bring about a reduction in the number of frivolous medical malpractice lawsuits that are filed and to limit inflated jury awards. Opponents to tort reform claim it limits a patient's right to recover for injuries resulting from medical error.

Number 233. Damages awarded by a jury that include pain and suffering, anxiety, distress, inconvenience, mental anguish, injury to reputation, hardship, loss of enjoyment of life, etc.

Correct Answer: Non-economic

Number 234. Non-economic damages are awarded by a jury that include pain and suffering, anxiety, distress, inconvenience, mental anguish, injury to reputation, hardship, loss of enjoyment of life, etc.

Number 235. In Tennessee, this rule of law bars a medical malpractice claim after one year from the date the injury is discovered.

Correct Answer: Statute of Limitations

Number 236. The statute of limitations in Tennessee bars a patient's claim of medical malpractice after one year from the date the injury is discovered.

Number 237. Under Tennessee law, this bars a medical malpractice claim 3 years after the alleged negligence occurred.

Correct Answer: Statute of Repose

Number 238. In Tennessee, the statute of repose bars a medical malpractice claim 3 years after the alleged negligence occurred.

Number 239. An initial act which sets off a natural and continuous sequence of events that produces an injury.

Correct Answer: Proximate Cause

Number 240. Proximate cause is an initial act which sets off a natural and continuous sequence of events that produces an injury.

Number 241. The thing speaks for itself.

Correct Answer: Res Ipsa Loquitur

Number 242. Res Ipsa Loquitur is the Latin phrase that means "The thing speaks for itself.

Number 243. A breach of duty based upon the defendant's violation of a statute or regulation.

Correct Answer: Negligence per se

Number 244. Negligence per se is a breach of duty based upon the defendant's violation of a statute or regulation.

Number 245. The legal term for a civil wrong.

a. Tart
b. Misdemeanor
c. Felony
d. Uncivil
e. Tort

Correct Answer: e. Tort

Number 246. Which of the following is an element that the plaintiff must prove in a medical malpractice case?

a. Intent
b. Malice
c. Insurance coverage
d. Proximate cause

Correct Answer: d. Proximate cause

Feedback: Under Tennessee law, there are three elements that a plaintiff must prove in a medical malpractice lawsuit: (1) the recognized standard of acceptable professional practice in the same or similar community in which the defendant practices; (2) that the defendant failed to act with ordinary and reasonable care in accordance with that standard; and (3) as a proximate result of the defendant's negligent act or omission, the plaintiff suffered injuries which would not otherwise have occurred. Tenn. Code Ann. Section 29-26-115.

Number 247. Which of the following is NOT an element of a medical malpractice lawsuit?

a. Duty owed to plaintiff
b. Breach of a duty that is owed to plaintiff
c. Injuries that were proximately caused by the breach of duty
d. Damages
e. Intent to breach a duty owed to plaintiff

Correct Answer: e. Intent to breach a duty owed to plaintiff

Feedback: Tenn. Code Ann. Section 29-26-115. See also, Kelley v. Middle Tennessee Emergency Physicians P.C., 133 S.W.3d 587 (Tenn. 2004).

Number 248. Describes the situation where medical malpractice insurance becomes unavailable or unaffordable, resulting in physicians leaving the practice of medicine or limiting their practices to low risk procedures.

a. Malpractice crisis
b. Insurance gouging
c. Controlling health care costs
d. Going "bare"
e. Risk management

Correct Answer: a. Malpractice crisis

Number 249. Describes the situation where medical malpractice insurance becomes unavailable or unaffordable, resulting in physicians leaving the practice of medicine or limiting their practices to low risk procedures.

Correct Answer: Malpractice crisis

Number 250. The "malpractice crisis" describes the situation where medical malpractice insurance becomes unavailable or unaffordable, resulting in physicians leaving the practice of medicine or limiting their practices to low risk procedures.

Number 251. For purposes of medical malpractice, which of the following is considered a low risk activity?

a. Delivering babies
b. Neurosurgery
c. Psychiatry
d. Emergency Medicine
e. Reading pap smears and mammograms

Correct Answer: c. Psychiatry

Number 252. In a June 2003 study, the GAO (General Accounting Office) concluded that this factor was the leading cause of rising malpractice insurance premiums in the long run.

a. Stock market losses
b. Losses on medical malpractice claims
c. Medical errors
d. Gouging
e. Risky investments

Correct Answer: b. Losses on medical malpractice claims

Feedback: GAO Report to Congressional Requesters: Medical Malpractice Insurance, Multiple Factors have contributed to increased premium rates. GAO-03-702. http://www.gao.gov/new.items/d03702.pdf Accessed November 21, 2007.

Number 253. How much of every dollar that is paid out in medical malpractice litigation goes to plaintiffs?

a. $.12
b. $.27
c. $.46
d. $.72
e. $.93

Correct Answer: c. $.46

Feedback: "Medical Malpractice Insurance,"Insurance Information Institute, June 2003, Vol. 1, Number 1. http://www.iii.org/media/hottopics/insurance/medicalmal/whitepaper/ Accessed November 21, 2007.

Number 254. The most common cause for an adversarial physician-patient relationship is:

a. Incompetency of physician
b. Noncompliance of patient
c. Lack of support staff
d. Failed communication
e. Uncomfortable hospital or clinic environment

Correct Answer: d. Failed communication

Feedback: JCAHO. http://www.jointcommission.org/NR/rdonlyres/FA465646-5F5F-4543-AC8F-E8AF6571E372/0/root(blank)cause(blank)se.jpg

Number 255. Generally, a hospital is least likely to be liable for the negligence of which of the following people?

a. Janitor
b. Nurse
c. Resident
d. Attending physician
e. Medical student

Correct Answer: d. Attending physician

Feedback: A hospital is liable for the negligence of its employees, and attending physicians often are not employees of the hospital. A physician in private practice must be granted privileges at a hospital before the physician may treat his or her patients in the hospital.

Number 256. The legal term to describe a physician in private practice who has hospital privileges, but who is not an employee of the hospital.

Correct Answer: Independent Contractor

Number 257. An independent contractor is the legal term to describe a physician in private practice who has hospital privileges, but who is not an employee of the hospital.

Number 258. How damages are allocated among doctors who are sued in the same medical malpractice case in Tennessee.

a. Equally
b. Jointly
c. Severally
d. Proportionately

Correct Answer: d. Proportionately

Feedback: Under comparative fault liability, a jury will allocate damages among the defendants according to their fault. Thus, if the jury finds that a defendant is responsible for only 5% of the plaintiff's damages, that defendant will be responsible for paying only 5% of the award. See, Carroll v. Whitney, 29 S.W.3d 14 (Tenn. 2000).

Number 259. Patient was injured due to a medical error. Although physician was negligent, he shows that Patient did not comply with treatment recommendations. Which of the following legal concepts is most likely either to bar or to reduce Plaintiff's award?

a. Contributory negligence
b. Mitigation of damages
c. Comparative negligence
d. Assumption of the risk
e. Noncompliancy

Correct Answer: c. Comparative negligence

Feedback: If the patient's injury was caused, in part, by his or her own negligence, the jury award will be reduced by the percentage of fault attributed to the patient. If the jury finds that the patient was 50% or more negligent, the patient is barred from recovering. This concept is known as "comparative negligence" or "comparative fault" because it compares the negligence of the plaintiff to that of the defendant. See, Carroll v. Whitney, 29 S.W.3d 13 (Tenn. 2000).

Number 260. Legal concept that reduces or bars a plaintiff's award. Plaintiff is not entitled to recover damages if plaintiff is 50% or more responsible for his injuries.

Correct Answer: Comparative Negligence

Number 261. Under a comparative negligence or comparative fault system, a plaintiff's award is barred from recovering damages if plaintiff is 50% or more responsible for his injuries. If plaintiff is less negligent than the defendant, a defendant is liable only for the percentage of damages caused by his own fault or negligence.

Number 262. Legal concept that bars a plaintiff's claim. Plaintiff cannot recover damages if by ordinary care he could have avoided the consequences of defendant's negligence. Tennessee abandoned this doctrine in 1992. See, McIntyre v. Balentine, 833 S.W.2d 52 (Tenn. 1992).

Correct Answer: Contributory Negligence

Number 263. Contributory negligence is a legal concept that bars a plaintiff's claim. Plaintiff cannot recover damages if by ordinary care he could have avoided the consequences of defendant's negligence. Tennessee abandoned the doctrine of contributory negligence in 1992. See, McIntyre v. Balentine, 833 S.W.2d 52 (Tenn. 1992).

Number 264. Legal concept that requires a person who is injured by another person's negligence to reduce his damages as far as practicable by the use of ordinary care.

Correct Answer: Mitigation of Damages

Number 265. "Mitigation of damages" is the legal concept that requires a person who is injured by another person's negligence to reduce his damages as far as practicable by the use of ordinary care.

Number 266. When a person has given his express consent to relieve another person of an obligation toward him and to take his chances of injury from a known risk.

Correct Answer: Assumption of the Risk

Number 267. Assumption of the risk is a legal concept that allows a person to give his express consent to relieve another person of an obligation toward him and to take his chances of injury from a known risk.

Number 268. Patient continued to suffer severe pain after his knee replacement operation. Subsequent surgery showed that the surgeon had put the knee replacement joint in backwards. What kind of an expert does plaintiff need to show a deviation from the standard of care?

a. An orthopedic surgeon
b. A general surgeon
c. A surgeon who has practiced or taught for 3 of the past 5 years
d. No expert is needed

Correct Answer: d. No expert is needed

Feedback: No expert is needed because lay people can understand that putting an artificial knee in backwards is negligent. See, Sood v. Smeigh, 259 Ga. App. 490 (2003).

Number 269. A type of evidence that can be used to infer another fact. It implies something occurred but doesn't directly prove it.

Correct Answer: Circumstantial

Number 270. Circumstantial evidence is a type of evidence that can be used to infer another fact. It implies something occurred but doesn't directly prove it.

Number 271. An instruction to the jury when the evidence suggests that the negligence claim is premised on later-acquired knowledge or information not known or reasonably available to the defendant physician at the time he or she provided medical care.

Correct Answer: Hindsight

Number 272. A hindsight instruction is given to the jury when the evidence suggests that the negligence claim is premised on later-acquired knowledge or information not known or reasonably available to the defendant physician at the time he or she provided medical care.

Number 273. Physician prescribes a new medication for Patient's heartburn. Several years later, studies show that prolonged use of the medication can result in kidney failure. Tests show that Patient's kidneys are failing and he will soon need dialysis. If Patient sues Physician for malpractice, which one of the following facts will be most helpful to Physician?

a. No alternative explanations for Patient's kidney failure can be shown.
b. At the time, the standard of care was to prescribe this medication for Patient's symptoms.
c. The studies have been generally accepted by the scientific community as reliable.
d. The evidence is circumstantial.

Correct Answer: b. At the time, the standard of care was to prescribe this medication for Patient's symptoms.

Feedback: Plaintiff must prove what the standard of care was at the time the alleged injury or wrongful action occurred.
Tenn. Code Ann. Section 29-26-115(a)(1).

Number 274. Patient suffered a severe adverse reaction to anesthesia during surgery that caused an interruption to Patient's oxygen supply resulting in massive brain trauma and death. At trial, plaintiff's expert testified that he personally would have pre-oxygenated Patient before surgery. Which of the following words best describes this testimony from a legal perspective?

a. Conclusive
b. Circumstantial
c. Hindsight
d. Direct
e. Irrelevant

Correct Answer: e. Irrelevant

Feedback: An expert's opinion as to what he or she would have done in similar circumstances is irrelevant. The standard of care that is owed by a physician to a patient is that which is employed by the medical profession generally, and not what one individual physician would do under the same or similar circumstances. See generally, Click v. Mangione, M1999-00129-COA-R3-CV (Tenn. Ct. App. 2000). See also, Johnson v. Riverdale Anesthesia Associates, 275 Ga. 240 (2202).

Number 275. Bars a patient's medical malpractice claim within 1 year after the patient's injuries are discovered.

a. State of repose
b. Statute of limitations
c. Equitable estoppel
d. Waiver
e. Laches

Correct Answer: b. Statute of limitations

Feedback: Tenn. Code Ann. Section 29-26-116.

Number 276. Bars a patient's medical malpractice claim 3 years after the alleged negligent act or omission occurred.

a. Statute of repose
b. Statute of limitations
c. Equitable estoppel
d. Waiver
e. Laches

Correct Answer: a. Statute of repose

Feedback: Tenn. Code Ann. Section 29-26-116.

Number 277. On August 4, 1998, Surgeon failed to remove a sponge from Patient's body cavity during surgery. On January 13, 2004, Patient began to experience symptoms that later turned out to be associated with the sponge left in his body. On March 4, 2005, exploratory surgery revealed the sponge, and it was removed. When is Patient's claim for malpractice against the original surgeon barred because it is too old?

a. March 4, 2006
b. March 4 2008
c. January 13, 2005
d. August 4, 2001
e. August 4, 1999
f. January 13, 2007

Correct Answer: a. March 4, 2006

Feedback: The statute of limitations for a foreign object left in a patient's body is one year from the date it was discovered or should have been discovered. The statute of repose does not apply to foreign object cases because there is no danger of old, stale claims being brought that are difficult to defend. A foreign object left in a patient's body can be easily traced back to the negligent surgeon. Tenn. Code Ann. 29-26-116(a)(4).

Number 278. A type of evidence that can be used to infer another fact. It implies something occurred but doesn't directly prove it.

a. Circumstantial
b. Sequential
c. Prejudicial
d. Irrelevant
e. Direct

Correct Answer: a. Circumstantial

Number 279. The length of time that a patient has to sue for a foreign object negligently left in his or her body.

a. 3 years from the date patient begins to experience symptoms.
b. 3 years from the date the foreign object was left in patient's body.
c. 1 year from the date the patient begins to experience symptoms.
d. 1 year from the date the foreign object is or should have been discovered.
e. 3 years from the date the foreign object is or should have been discovered.
f. 1 year from the date the foreign object was left in the patient's body

Correct Answer: d. 1 year from the date the foreign object is or should have been discovered.

Feedback: The statute of repose does not apply in foreign object cases. Tenn. Code Ann. Section 29-26-116(a)(4).

Number 280. Patient's medical chart indicates that there are no known allergies. To treat an infection, Physician prescribes a sulfa-based antibiotic. Patient has a severe allergic reaction to the medication and dies. At trial, the jury should be instructed on which of the following legal concepts?

a. Ignorance
b. Contributory negligence
c. Comparative negligence
d. Res ipsa loquitur
e. Hindsight

Correct Answer: e. Hindsight

Feedback: A hindsight jury instruction is appropriate when the evidence suggests that the negligence claim is premised on later-acquired knowledge or information not known or reasonably available to the defendant physician at the time he provided medical care.

Number 281. A psychiatric disorder, alcohol dependence, or drug dependence, but does not include mental retardation or other developmental disabilities.

Correct Answer: Mental Illness

Number 282. "Mental illness" means a psychiatric disorder, alcohol dependence, or drug dependence, but does not include mental retardation or other developmental disabilities.

Number 283. A condition characterized by the continuous or episodic use of alcohol resulting in social impairment, vocational impairment, psychological dependence or pathological patterns of use.

Correct Answer: Alcohol abuse

Number 284. "Alcohol abuse" means a condition characterized by the continuous or episodic use of alcohol resulting in social impairment, vocational impairment, psychological dependence or pathological patterns of use.

Number 285. Alcohol abuse that results in the development of tolerance or manifestations of alcohol abstinence syndrome upon cessation of use.

Correct Answer: Alcohol dependence

Number 286. "Alcohol dependence" means alcohol abuse that results in the development of tolerance or manifestations of alcohol abstinence syndrome upon cessation of use.

Number 287. A condition characterized by the continuous or episodic use of a drug or drugs resulting in social impairment, vocational impairment, psychological dependence or pathological patterns of use.

Correct Answer: Drug Abuse

Number 288. "Drug abuse" means a condition characterized by the continuous or episodic use of a drug or drugs resulting in social impairment, vocational impairment, psychological dependence or pathological patterns of use.

Number 289. Drug abuse that results in the development of tolerance or manifestations of drug abstinence syndrome upon cessation of use.

Correct Answer: Drug dependence

Number 290. "Drug dependence" means drug abuse that results in the development of tolerance or manifestations of drug abstinence syndrome upon cessation of use.

Number 291. A program or treatment for mental illness within a hospital facility setting.

Correct Answer: Inpatient Treatment

Number 292. "Inpatient treatment" is a program or treatment for mental illness within a hospital facility setting.

Number 293. A program of treatment for mental illness outside a hospital facility setting which includes medication and prescription monitoring, individual or group therapy, day or partial programming activities, case management services, and other services to alleviate or treat the patient's mental illness so as to maintain the patient's semi-independent functioning and to prevent the patient from becoming an inpatient.

Correct Answer: Outpatient Treatment

Number 294. "Outpatient Treatment" is a program of treatment for mental illness outside a hospital facility setting which includes medication and prescription monitoring, individual or group therapy, day or partial programming activities, case management services, and other services to alleviate or treat the patient's mental illness so as to maintain the patient's semi-independent functioning and to prevent the patient from becoming an inpatient.

Number 295. A document filed with the court to question the cause and legality of detention and to request the court to issue a writ for release.

Correct Answer: Habeas Corpus

Number 296. "Habeas corpus" is a document filed with the court to question the cause and legality of detention and to request the court to issue a writ for release.

Number 297. A patient who has been admitted into a mental health facility for treatment by court order.

a. A voluntary inpatient
b. An involuntary inpatient
c. A voluntary outpatient
d. An involuntary outpatient

Correct Answer: b. An involuntary inpatient

Feedback: Tenn. Code Ann. Section 33-3-617.

Number 298. A patient who attends group therapy in a community setting pursuant to a court order.

a. A voluntary inpatient
b. An involuntary inpatient
c. A voluntary outpatient
d. An involuntary outpatient

Correct Answer: d. An involuntary outpatient

Feedback: Tenn. Code Ann. Section 33-6-602.

Number 299. A condition based upon having either a severe chronic disability or mental retardation.

Correct Answer: Developmental disability

Number 300. "Developmental disability" means a condition based upon having either a severe chronic disability or mental retardation.

Number 301. A person who is licensed in the state, if required for the profession, and who is a psychiatrist; physician with expertise in psychiatry as determined by training, education, or experience; psychologist with health service provider designation; psychological examiner or senior psychological examiner; social worker who is certified with two (2) years of mental health experience or is licensed; marital and family therapist; nurse with a master's degree in nursing who functions as a psychiatric nurse; professional counselor; or if the person is providing service to service recipients who are children, any of the above educational credentials plus mental health experience with children

Correct Answer: Qualified mental health professional

Number 302. “Qualified mental health professional” means a person who is licensed in the state, if required for the profession, and who is a psychiatrist; physician with expertise in psychiatry as determined by training, education, or experience; psychologist with health service provider designation; psychological examiner or senior psychological examiner; social worker who is certified with two (2) years of mental health experience or is licensed; marital and family therapist; nurse with a master's degree in nursing who functions as a psychiatric nurse; professional counselor; or if the person is providing service to service recipients who are children, any of the above educational credentials plus mental health experience with children.

Number 303. The parent of an unemancipated child with mental illness, serious emotional disturbance, alcohol dependence, drug dependence, or developmental disabilities who is receiving service in programs of the department or any relative who accepts financial responsibility for the care and service of a service recipient

Correct Answer: Responsible relative

Number 304. "Responsible relative" means the parent of an unemancipated child with mental illness, serious emotional disturbance, alcohol dependence, drug dependence, or developmental disabilities who is receiving service in programs of the department or any relative who accepts financial responsibility for the care and service of a service recipient.

Number 305. Patient, who was involuntarily committed, refuses his medication. Under Tennessee law, can the physician administer the medication over Patient's objections? Assume Patient has capacity to make health care decisions.

a. No, not without a court order.
b. Yes, because Patient doesn't have the right to object.
c. No, Patient has the right to refuse medication.
d. Yes, but only if patient's Treatment Review Committee approves.

Correct Answer: d. Yes, but only if patient's Treatment Review Committee approves.

Feedback: Tenn. Code Ann. Section 33-6-107(d): "A person committed involuntarily to a hospital or treatment resource who does not lack capacity to make a decision on treatment may be given treatment over the service recipient's objection only if the service recipient's treatment review committee approves the treatment."

The Tennessee Department of Mental Health provides regulations for administering medication under emergency situations prior to review by the treatment review committee. Rule 0940-1-1-.05. These regulations are available from the Web site at http://www.tennessee.gov/mental/

The answer to this question may vary from state to state. Some states require a court order to treat an involuntarily committed patient over his or her objection. Under Georgia law, a patient has the right to refuse medication, unless a physician determines that the refusal would be unsafe for the patient or others. If the patient continues to refuse after the initial emergency treatment, the physician must obtain and document the concurring opinion of another physician before continuing medication. O.C.G.A. Section 37-7-163(b).

Number 306. A condition in a child who currently or at any time during the past year has had a diagnosable mental, behavioral, or emotional disorder of sufficient duration to meet psychiatric diagnostic criteria that results in functional impairment that substantially interferes with or limits the child's role or functioning in family, school, or community activities and includes any mental disorder, regardless of whether it is of biological etiology.

Correct Answer: Serious emotional disturbance

Number 307. "Serious emotional disturbance" means a condition in a child who currently or at any time during the past year has had a diagnosable mental, behavioral, or emotional disorder of sufficient duration to meet psychiatric diagnostic criteria that results in functional impairment that substantially interferes with or limits the child's role or functioning in family, school, or community activities and includes any mental disorder, regardless of whether it is of biological etiology.

Number 308. Patient tells Psychiatrist that he intends to kill his wife because she is cheating on him. He has bought a gun, and it is just a matter of waiting for the right opportunity. Under Tennessee law, what is Psychiatrist's preferred course of action?

a. Warn Patient's wife
b. Notify local law enforcement
c. Do nothing because this is a family matter.
d. Wait until there is stronger evidence that Patient is a danger to himself or others

Correct Answer: a. Warn Patient's wife

Feedback: Tenn. Ann. Code Sections 33-3-206 and 33-3-207. Psychiatrist has a duty to warn or take precautions to protect the wife in this case. Under Tennessee law, Psychiatrist may discharge this duty by (1) informing the clearly identified victim of the threat; (2) have the patient admitted on a voluntary basis to a hospital; (3) initiate involuntary commitment proceedings against the patient; or (4) pursue a course of action consistent with current professional standards that will discharge the duty. If the current professional standard is to notify law enforcement, then that choice may also be a correct response to this question.

Most states follow this rule, which was originally articulated in Tarasoff v. Regents of Univ. of California, 529 P.2d 553 (Cal. 1974), However, Georgia does not clearly recognize the duty to warn, and a psychiatrist or other mental health professional risks breaching a duty of confidentiality by disclosing this type of information. Georgia has adopted the Bradley Center rule, that imposes liability for harm to third parties when the physician had a duty to control the patient and the harm was foreseeable. In Georgia, a psychiatrist's preferred option would be to initiate involuntary commitment proceedings. See, Bradley Center v. Wessner, 250 Ga. 199 (1982).

Number 309. A document executed by a physician or qualified licensed psychologist stating that he or she has personally examined a person within the past three days, and that the person is in need of commitment for care and treatment for mental illness, serious emotional disturbance, or developmental disability.

Correct Answer: Certificate of Need

Number 310. "Certificate of need" is a document executed by a physician or qualified licensed psychologist stating that he or she has personally examined a person within the past three days, and that the person is in need of commitment for care and treatment for mental illness, serious emotional disturbance, or developmental disability.

Number 311. A person who is receiving service, has applied for service, or for whom someone has applied for or proposed service because the person has mental illness, serious emotional disturbance, or a developmental disability.

Correct Answer: Service recipient

Number 312. "Service recipient" means a person who is receiving service, has applied for service, or for whom someone has applied for or proposed service because the person has mental illness, serious emotional disturbance, or a developmental disability.

Number 313. A condition in which an adult or an emancipated child: (1) As a result of a mental illness or serious emotional disturbance: (A) Is in danger of serious physical harm resulting from the person's failure to provide for the person's essential human needs of health or safety; or (B) Manifests severe deterioration in routine functioning evidenced by repeated and escalating loss of cognitive or volitional control over the person's actions; and (2) Is not receiving care that is essential for the person's health or safety

Correct Answer: Severe impairment

Number 314. "Severe impairment" means a condition in which an adult or an emancipated child: (1) As a result of a mental illness or serious emotional disturbance: (A) Is in danger of serious physical harm resulting from the person's failure to provide for the person's essential human needs of health or safety; or (B) Manifests severe deterioration in routine functioning evidenced by repeated and escalating loss of cognitive or volitional control over the person's actions; and (2) Is not receiving care that is essential for the person's health or safety.

Number 315. Patient is a 52-year old woman who is mentally ill. Her husband believes that she would be better off in a hospital for the mentally ill. Will he be successful in having her committed?

a. Yes, because she is mentally ill.
b. Yes, as long as his insurance covers her stay.
c. No, not unless she poses a substantial likelihood of serious harm.
d. Yes, if she doesn't object when he has her admitted.
e. No, unless he can find a physician who will certify that she is in need of commitment.

Correct Answer: c. No, not unless she poses a substantial likelihood of serious harm.

Feedback: Tenn. Code Ann. Section 33-6-510. Due process requires that certain procedures must be followed before detaining someone in a mental health facility. The fact of mental illness alone is not sufficient reason to commit someone. One physician's opinion is not sufficient to have someone committed to a mental health facility.

Number 316. When someone knowingly removes or confines another unlawfully so as to interfere with the other's liberty.

Correct Answer: False imprisonment

Number 317. "False imprisonment" occurs when someone knowingly removes or confines another unlawfully so as to interfere with the other's liberty.

Number 318. Patient visits a clinic on her lunch hour to discuss her suicidal thoughts. After examining her, Psychiatrist tells her that he would like to admit her for observation. She refuses and tries to leave. Psychiatrist detains her against her will until the sheriff comes to transport her to an inpatient mental health facility. Does she have a cause of action against Psychiatrist?

a. Yes, she can sue him for false imprisonment.
b. No, he was justified in detaining her if he believed she was in need emergency detention.
c. Yes, he needed a warrant to detain her.
d. No, a physician may detain a patient for up to 72 hours.

Correct Answer: b. No, he was justified in detaining her if he believed she was in need emergency detention.

Feedback: Tenn. Code Ann. Section 33-6-402 provides: If any of the following persons have reason to believe that a person is subject to emergency detention, they may take the person into custody without a civil order or warrant for immediate examination for certification of need for care and treatment: (1) officer authorized to make arrests in the state; (2) a licensed physician; (3) an authorized psychologist; or (4) a qualified mental health professional designated by the commissioner.

Number 319. Upon a determination of two doctors that a person is severely impaired, how long may a patient be detained after being brought to a treatment resource?

a. 72 hours
b. 24 hours
c. 7 days
d. 6 hours
e. 12 hours

Correct Answer: a. 72 hours

Feedback: If a person with a severe impairment is detained and brought to a treatment resource, the person must be examined by a physician within six hours of being brought to the treatment resource. If the examining physician finds that the person meets the legal requirements of "severe impairment," the person may be detained for up to 12 hours. If a second physician examines the person within the 12 hour period and confirms the diagnosis, the person may be detained for up to 72 hours. Tenn. Code Ann. Sections 33-6-302, 33-6-303, 33-6-304, and 33-6-305. If it is necessary to hold the person longer than 72 hours, other procedures must be followed.

Number 320. What procedure should be used for detaining a person who is determined to be "severely impaired" beyond the time allowed by law?

a. Habeas corpus
b. Re-certification of need
c. Emergency Involuntary Commitment Proceedings
d. Detention with warrant

Correct Answer: c. Emergency Involuntary Commitment Proceedings

Feedback: Tenn. Code Ann. Section 33-6-309. If at any time within the 72 hour period it is determined that the person continues to require immediate observation, assessment, and treatment and that need will continue beyond the 72 hour period, the person shall be moved immediately to an appropriate treatment resource that is qualified to receive and detain persons with mental illness or serious emotional disturbance. The person shall be evaluated and, if appropriate, admitted in accordance with the emergency detention procedures.

Number 321. Someone who meets the medical and legal criteria may be held under the emergency involuntary detention procedures for up to 15 days after what occurs?

a. A judge finds probable cause for admission after a probable cause hearing.
b. Two physicians file a certificate of need for treatment
c. The chief officer of the facility determines that the person is subject to admission.
d. The persons signs a consent form.

Correct Answer: a. A judge finds probable cause for admission after a probable cause hearing.

Feedback: Tenn. Code Ann. Section 33-6-422. Before a person may be held for the 15 days emergency detention under the emergency involuntary commitment procedures, a judge must enter an order after a probable cause hearing, unless the person has waived the hearing. Prior to the probable cause hearing, two certificates of need must be filed with the court, and the chief officer of the facility has made the determination that the person is subject to admission. If the person signs a consent form for admission, there is no need to initiate the emergency detention procedures.

If there is a need to hold the person longer than 15 days, other procedures must be initiated.

Number 322. If a person is being held under the emergency detention procedure, what must be done to hold the person longer than 15 days?

a. Request the court to extend the emergency detention.
b. The chief officer of the facility notifies the court of the extended detention and the reasons for it.
c. File a complaint for involuntary commitment within the 15 days.
d. Nothing. The person must be released.

Correct Answer: c. File a complaint for involuntary commitment within the 15 days.

Feedback: Tenn. Code Ann. Section 33-6-422.

Number 323. Patient was admitted under the emergency detention procedures. On the 10th day of detention, Psychiatrist determines that Patient no longer poses a substantial likelihood of serious harm. What must be done under the law?

a. Discharge after two other physicians confirm the diagnosis.
b. Discharge the patient as soon as it is feasible to do so.
c. Nothing, the facility may detain the person for the full 15 days.
d. File a writ of habeas corpus with the court.

Correct Answer: b. Discharge the patient as soon as it is feasible to do so.

Feedback: Tenn. Code Ann. Section 33-6-705. If a person is admitted to a hospital for treatment of mental illness or serious emotional disturbance under any provision of this law (except for nonemergency involuntary commitment) and the person no longer meets the standards under which the admission took place, and the person's detention is not otherwise authorized, then "the person shall be discharged."

Number 324. A complaint for nonemergency commitment must be filed with two certificates of need.

a. True
b. False

Correct Answer: b. False

Feedback: Tenn. Code Ann. Section 33-3-602. Although two certificates of need must be filed with the court, they need not be filed with the complaint if the defendant has refused to be examined by a certifying professional. In this case, the complaint may be filed with a sworn statement from the plaintiff that the defendant has refused to be examined by certifying professionals.

Tenn. Code Ann. Section 33-3-607. If the court finds probable cause to believe that the defendant is subject to involuntary care and treatment and has refused to be examined by a certifying professional, the court shall order a law enforcement officer to take the defendant into custody for an examination by two certifying professionals who meet the requirements of the commitment statute. The defendant may be detained for the period required to complete the examinations, but not more than 48 hours. Upon completion of the examinations, the person shall be released, and the certifying professionals shall report their findings to the court.

Number 325. A certificate of need must state which of the following?

a. That the certifying professional personally examined the person within the past three days.
b. That the certifying professional is of the opinion that the person is subject to involuntary care and treatment under the commitment statute.
c. The factual foundation for their conclusions on each item of the commitment statute.
d. All of the above.

Correct Answer: d. All of the above.

Feedback: Tenn. Code Ann. Section 33-6-602.

Number 326. A patient is brought to the ER to be evaluated for emergency detention. The ER physician examines her and determines that emergency detention is appropriate. The ER physician goes off duty, and she is relieved by another ER physician. The second ER physician reviews Patient's medical chart and the notes of the first ER physician, and signs a certificate of need. He does not speak with or examine Patient. Was this appropriate?

a. No, he has committed a misdemeanor.
b. No, he has committed a felony.
c. Yes, she was examined by a physician within 3 days.
d. Yes, because she will be reexamined when she is admitted to the treatment facility.
e. Yes, because she met the criteria for emergency detention.

Correct Answer: b. No, he has committed a felony.

Feedback: Tenn. Code Ann. Section 33-4-108(b): "The execution of a certificate concerning the mental condition of a person by a professional who has not personally observed and examined the person is a Class E felony."

See also, Vickroy v. Pathways, Inc., (unpublished opinion) (Tenn. 2004) (holding that physician signing a certificate of need for treatment of mental illness without personally examining patient created a cause of action for negligence per se and false imprisonment).

Number 327. After a person has been involuntarily committed under the nonemergency commitment procedure, how often must the chief officer of the facility review his or her case to see if the person is eligible for discharge?

a. Once every year
b. Each time the person requests discharge.
c. Every three months.
d. Every six months

Correct Answer: d. Every six months

Feedback: Tenn. Code Ann. Section 33-6-701. "The chief officer of a public or private hospital shall, as often as practicable, but not less often than every six (6) months, examine or cause to be examined each person admitted under this title for treatment of mental illness or serious emotional disturbance. "

Number 328. Expresses a person's preferences and instructions about how he or she wants to be treated or not treated when he or she lacks capacity to make informed decisions about his or her mental health treatment.

Correct Answer: Declaration for Mental Health Treatment

Number 329. "Declaration for Mental Health Treatment" is a document that expresses a person's preferences and instructions about how he or she wants to be treated or not treated when he or she lacks capacity to make informed decisions about his or her mental health treatment.

Number 330. Failure to follow the statutory procedures for detaining someone for involuntary observation, assessment, and treatment may be a violation of what constitutional right?

a. Autonomy
b. Equal protection
c. Due process
d. Privacy

Correct Answer: c. Due process

Feedback: State of Tenn. v. Phillips, 968 S.W.2d 874, 879 (Tenn. Crim. App. 1996) ("involuntary commitment to a mental institution constitutes a deprivation of liberty that invokes the constitutional protection of procedural due process.")

Number 331. Placement of a person alone in a room from which egress is prevented. May be used in an emergency to assure the physical safety of the patient or of another, or to prevent significant property destruction. It may not be used as a means of coercion, discipline, convenience, or retaliation by staff.

Correct Answer: Isolation

Number 332. "Isolation" means the placement of a person alone in a room from which egress is prevented. It may be used in an emergency to assure the physical safety of the patient or of another, or to prevent significant property destruction. It may not be used as a means of coercion, discipline, convenience, or retaliation by staff.

Number 333. They include physical and mechanical, as well as drugs used to control behavior or to restrict freedom of movement. They may be used in an emergency to assure the physical safety of the patient or of another, or to prevent significant property destruction. They may not be used as a means of coercion, discipline, convenience, or retaliation by staff.

Correct Answer: Restraints

Number 334. "Restraints" include physical and mechanical restraints, as well as drugs used to control behavior or to restrict freedom of movement. They may be used in an emergency to assure the physical safety of the patient or of another, or to prevent significant property destruction. They may not be used as a means of coercion, discipline, convenience, or retaliation by staff.

Number 335. A document filed with the court to question the cause and legality of detention and to request the court to issue a writ for release.

a. Res Ipsa Loquitur
b. Request for Writ of Release
c. Writ of post hoc ergo propter hoc
d. Writ of Habeas Corpus

Correct Answer: d. Writ of Habeas Corpus

Feedback: Tennessee Code Annotated Section 33-3-801

Number 336. For the purpose of emergency involuntary commitment to a state-owned hospital or treatment resource, who should be asked to provide one of the certificates of need?

a. Mandatory prescreening agent
b. Psychologist
c. Board certified Psychiatrist
d. Licensed Physician

Correct Answer: a. Mandatory prescreening agent

Feedback: Tennessee Code Annotated Section 33-6-105. If there is no mandatory prescreening agent available to examine the person within 2 hours of the request, then a licensed physician or licensed psychologist with health service provider designation may examine the person and may provide one the certificates if the physician or psychologist, in consultation with a member of the crisis response service designated by the commissioner to serve the county, determines that all available less drastic alternatives to placement in a hospital or treatment resource are unsuitable to meet the needs of the person.

Number 337. The Treatment Review Committee may not override a decision made by which of the following people?

a. Adult patient with capacity
b. Emancipated minor with capacity
c. Parent
d. Health care agent

Correct Answer: c. Parent

Feedback: Tennessee Code Annotated Section 33-6-107(c) states: "The treatment review committee shall not override a decision by a parent, legal custodian, or legal guardian of a service recipient who is an unemancipated child, or a conservator of a service recipient."
"(d) A person committed involuntarily to a hospital or treatment resource who does not lack capacity to make a decision on treatment may be given treatment over the service recipient's objection only if the service recipient's treatment review committee approves the treatment."

Number 338. For purposes of voluntary admission to a mental health facility, how old must the person be to apply for admission to a public or private hospital for diagnosis, observation, and treatment for a mental illness or serious emotional disturbance?

a. 12
b. 21
c. 18
d. 16

Correct Answer: d. 16

Feedback: Tennessee Code Annotated Section 33-6-201.

Number 339. Under Tennessee law, a physician must retain a patient's medical records for at least this many years.

a. 2
b. 6
c. 10
d. 15
e. 25

Correct Answer: c. 10

Feedback: Tennessee requires longer retention periods of certain types of records, such as immunizations and mammograms. Records for minors and incompetents also must be kept for longer periods.

In addition, ethical considerations may justify retaining medical records longer than the minimum required time. The AMA suggests the following rule of thumb: Whether the doctor would want the information if he or she were seeing the patient for the first time. Such records may include immunizations, chemotherapy notes, operative notes, etc. Old records should be destroyed. If feasible, patients should be given the option to claim the records or have them sent to another doctor. AMA Code of Medical Ethics, Section 7.05.
Tenn. Code Ann. Section 68-11-305.

Number 340. When a verbal order is taken over the phone, JCAHO strongly recommends that the person taking the order do which of the following?

a. Repeat the order twice.
b. Read the order back.
c. Write it directly in the patient's medical record.
d. Make multiple copies.

Correct Answer: b. Read the order back.

Feedback: This is known as the "Read Back Rule." If the order is written and read back, rather than repeated and then written, the physician can be assured that the order is correct. JCAHO recognizes that in emergency situations it is acceptable to repeat the order back when it is not feasible to do a formal "read-back."
http://www.jointcommission.org/NR/rdonlyres/A6839682-0A43-4053-86FB-923257674F09/0/07(blank)NPSG(blank)FAQs(blank)2.pdf

Number 341. Which of the following medical record entries would have JCAHO's approval?

a. 4 U of blood
b. To be taken Q.O.D.
c. 0.9 micrograms
d. Take 2 tablets @ bedtime

Correct Answer: c. 0.9 micrograms

Feedback: Never write 0 after a decimal, and always write a 0 before a decimal.
JCAHO "Do Not Use List."
http://www.jointcommission.org/PatientSafety/NationalPatientSafetyGoals/

Number 342. Medical records serve many purposes. What is their most important role?

a. Defense of lawsuits
b. Delivery of appropriate and timely care to patients
c. Quality assurance and risk management
d. Regulatory compliance
e. Reimbursement for services

Correct Answer: b. Delivery of appropriate and timely care to patients

Number 343. Which of the following is usually not included in response to subpoenas or authorizations?

a. Interpretations and analysis of tests and diagnostic procedures
b. Medication records
c. Consent forms
d. Discharge summaries
e. Source data

Correct Answer: e. Source data

Feedback: Source data is defined to include raw data from psychological and neuropsychological tests, radiological films and images, videotapes, monitoring strips, etc., provided that a professional interpretation or report of the source data is included in the record. 45 CFR 164.501(1). Source data is available if specifically requested.

Number 344. The information that is generally and traditionally released in response to subpoenas and authorizations.

Tennessee Health Information Management Association Legal Handbook, April 2006, page 5-17.

Correct Answer: Primary Medical Record

Number 345. The "primary medical record" is the information that is generally and traditionally released in response to subpoenas and authorizations.

Tennessee Health Information Management Association Legal Handbook, April 2006, page 5-17.

Number 346. JCAHO

Correct Answer: Joint Commission on Accreditation of Healthcare Organizations

Number 347. The acronym JCAHO stands for Joint Commission on Accreditation of Healthcare Organizations

Number 348. Creates an obligation to benefit patients and other persons and to further their welfare and interests.

Correct Answer: Beneficence

Number 349. Beneficence is an ethical concept that creates an obligation to benefit patients and other persons and to further their welfare and interests.

Number 350. Obligates physicians to protect and defend the informed choices of capable patients.

Correct Answer: Autonomy

Number 351. Autonomy is the legal and ethical concept that obligates physicians to protect and defend the informed choices of capable patients.

Number 352. An obligation to prevent harm or, if risks of harm must be taken, to minimize those risks.

Correct Answer: Nonmaleficence

Number 353. Nonmaleficence is an ethical obligation to prevent harm or, if risks of harm must be taken, to minimize those risks.

Number 354. Fairness of access to healthcare and to issues of rationing at the bedside.

Correct Answer: Justice

Number 355. Justice is the ethical concept that focuses on fairness of access to healthcare and to issues of rationing at the bedside.

Number 356. Patient, a 26-year old woman, is brought to the ER bleeding profusely from an open fracture of her leg. Two IV's are running. Her blood pressure is falling. She is conscious and speaking coherently. Physician tells her he needs to give her a blood transfusion. She refuses based upon her religious beliefs. After explaining that she may die without the blood transfusion, she again refuses. Her right to refuse is based upon:

a. Autonomy
b. Beneficence
c. Nonmaleficence
d. Justice
e. Substituted judgment

Correct Answer: a. Autonomy

Number 357. Patient, a 66-year old man, has severe liver damage. He usually has 6-10 alcoholic drinks per day, and on weekends, he increases his alcohol consumption. His history shows he is not likely to stop drinking, so any medical care to treat his liver disease is likely to be futile and a waste of medical resources. The decision on whether to refer him to a specialist for assessment involves which of the following ethical principles?

a. Autonomy
b. Beneficence
c. Nonmaleficence
d. Justice
e. Substituted judgment

Correct Answer: d. Justice

Feedback: Is this an acceptable reason to ration health care services?

Number 358. Patient, a 32-year old woman, has an aggressive form of cancer, and her life expectancy is less than six months. A clinical trial is testing a new cancer drug that may extend her life another six months, but its side effects are harsh and will significantly decrease the quality of her life. Encouraging her to enroll in the study may call into question which of the following ethical principles?

a. Autonomy
b. Beneficence
c. Nonmaleficence
d. Justice
e. Substituted judgment

Correct Answer: c. Nonmaleficence

Number 359. Patient is an 8-year-old boy who physician suspects may have leukemia. To confirm the diagnosis, the physician needs to raise Patient's hematocrit with blood transfusions before performing a bone marrow aspiration. The procedure has a low risk and high benefit. Patient's parents refuse on religious grounds. What ethical principle should most factor into the physician's decision on whether to seek a court order allowing the blood transfusions?

a. Autonomy
b. Beneficence
c. Nonmaleficence
d. Justice
e. Substituted judgment

Correct Answer: b. Beneficence

Feedback: Although parents have constitutionally protected rights, the United States Supreme Court has held that parents do not have the absolute right to make life or death decisions over their children. Thus, the overriding ethical concern in this case is the child's best interest, not the autonomy of the parents. See, Prince v. Commonwealth of Massachusetts, 321 U.S. 158 (1944). (parents do not have an absolute right to refuse medical treatment on behalf of their children.)

Number 360. Patient, an 78- year-old woman, is diagnosed with cancer. Her physician explains her diagnosis and options for treatment, their side effects and material risks, their likelihood of success, and the prognosis if treatment is rejected. She asks her physician to decide which treatment option is best for her, and the physician does so. This scenario illustrates which of the following principles?

a. Autonomy
b. Beneficence
c. Nonmaleficence
d. Justice
e. Paternalism

Correct Answer: a. Autonomy

Feedback: Physician has respected the patient's autonomy by accepting her decision to rely upon the recommendations of the physician. This scenario would be an example of paternalism if the physician made the decision for her without explaining the diagnosis, the purpose of the treatment, the material risks of the proposed treatment, the likelihood of success, alternative treatments and their risks and likelihood of success, and the prognosis if the proposed treatment is rejected. Autonomy includes the right to rely upon a physician's recommendations.

Number 361. Creates an obligation to benefit patients and other persons and to further their welfare and interests.

a. Autonomy
b. Beneficence
c. Nonmaleficence
d. Justice
e. Substituted judgment

Correct Answer: b. Beneficence

Number 362. Obligates physicians to protect and defend the informed choices of capable patients.

a. Autonomy
b. Beneficence
c. Nonmaleficence
d. Justice
e. Substituted judgment

Correct Answer: a. Autonomy

Number 363. An obligation to prevent harm, or if risks of harm must be taken, to minimize those risks.

a. Autonomy
b. Beneficence
c. Nonmaleficence
d. Justice
e. Substituted judgment

Correct Answer: c. Nonmaleficence

Number 364. Fairness of access to health care and to issues of rationing at the bedside.

a. Autonomy
b. Beneficence
c. Nonmaleficence
d. Justice
e. Substituted judgment

Correct Answer: d. Justice

Number 365. Application of the ethical principles beneficence and nonmaleficence ideally should achieve which of the following?

a. No harm done
b. Access to health care
c. All benefit
d. Self-rule
e. A net benefit.

Correct Answer: e. A net benefit.