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NBME 24 Answers

nbme24/Block 4/Question#12
A 25-year-old woman takes an overdose of ...
Extubate the patient and discontinue mechanical ventilation; make no attempt to do cardiopulmonary resuscitation in case of cardiac or respiratory failure🔍

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 +4  upvote downvote
submitted by m-ice(235),

The patient shows no sign of cortical activity, but has some brainstem function intact, which implies she is in a form of persistent vegetative state. She has a living will that designates mechanical ventilation should be discontinued if that situation arises, so we must follow it and make not attempt to resuscitate.

lfsuarez  Why would the second part of that be correct when there is not mention of a DNR? +7  
ug123  DNI and DNR are different right? This patient had a DNI. Why would we assume it to be DNR too? +2  
sherry  DNI and DNR are indeed different. But it is not the case here. The patient needs to be extubated means she did not sign a DNI or DNR in the first place. I assume her living will is more like terminate supporting treatment in a vegetative state. So there is no need to do resuscitation anyways. But I agree this is not a good question. +  
shayan  "The patient has signed the living will and is consistent with her directives" but the stem doesnt tell has what is in her living will about the extubation? we are extubating on the request of her husband? this is confusing ! +4  
criovoly  I believe this question was not well constructed... it's one of those! +  
suckitnbme  @shayan extubating at request of the husband because he's following what's in her living will. Following that line of thought, the patient probably wanted withdrawal of care if in a vegetative state. +  
luciana  I understood same as @shayan that she wanted to keep intubated... now reading it again I feel extra dumb with my poor reading interpretation skills +  



 +0  upvote downvote
submitted by poisonivy(20),

can we consider the overdose as a suicidal attempt? if so... wouldn't she be considered as without decision-making capacity?

em_goldman  People who are suicidal still have decision-making capacity; it's not equivalent to advanced dementia or other situations where decision making is impaired. Laws vary by state; I know in my state that the maximum time for holding someone against their will is 48 hours unless a court has deemed them incompetent and designated another person as their legal decision maker, including people who are actively suicidal. My understanding of the law as a layperson is that her living will was signed along with people bearing witness to the fact that she was the one who signed it, and it was what she wanted. Ethics aside, it would be almost impossible to prove that she legally initiated a DNR in a state of suicidality that was intense enough to interfere with her decision-making capacity in that moment. +  



 +0  upvote downvote
submitted by kenyaboi(1),

This is a f#$ked up question. its the ways its written. the husband is agreeing with the living will "consistent with its directive". so basically we would have to assume her will says DNR. needless confusion




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