Healthcare Ethics Consultation Examination Sample Questions

The sample questions below are designed to give you a clearer idea of what to expect on exam day. These questions were developed by ASBH volunteers, not item writers for the HEC-C Examination, and are provided as a sample of the question type and structure that you will encounter on the exam. The sample questions have not gone through review and validation in the same manner as of the questions that will appear on the HEC-C examination.

Application Information

To view the correct answer choices, click "read more" at the end of each sample question.

Sample question 1

A 71-year-old widow suffered a cardiac arrest while clearing the dinner table at home. Paramedics performed CPR for 21 minutes before circulation was restored. Since then, the patient has remained comatose, and it has become apparent that the patient has suffered irreversible anoxic brain injury. The ICU team approaches the family to recommend a Do Not Attempt Resuscitation (DNAR) order and suggest that the family consider withdrawal of life support to allow natural death. There is no designated healthcare agent. The patient has three adult daughters who do not agree on the goals of care. The youngest daughter states that she knows that her mother would not wish to continue living in this unconscious state. The other daughters refuse to consider the notion of DNAR or withdrawal. The palliative care team, already involved in the case, requests an ethics consultation to assist in mediating the daughters' conflicting perspectives.

The healthcare ethics consultant considers a number of hypotheses that might account for discordant perspectives among the patient's daughters. Which of these strategies is recommended if the HEC seeks to elicit the values perspectives of the daughters in this case?

1. Meet with the daughters with the expectation of listening to elicit and clarify each one's perspective.
2. Meet with the daughters to explain the hypotheses the HEC has considered that might account for the discordant perspectives.
3. Meet with the daughters, the medical team, and the palliative care team to observe the palliative care provider inquire about goals of care, with the expectation of clarifying and reframing elements of the conversation.
4. Meet with the daughters individually along with the palliative care provider to review the patient's condition and prognosis and elicit reasons why two of the daughters will not agree to DNAR and withdrawal of life support.

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Use the following information to answer sample questions 2–4.

A 71-year-old woman is hospitalized in the ICU with acute respiratory failure requiring mechanical ventilation and sedation. She has a long history of emphysema requiring long-term oxygen therapy, in addition to peripheral vascular disease and stable angina pectoris.

She was admitted a week ago for mild respiratory distress. In conversation with her husband and the physician during that admission, she voiced that she did not want life support treatment, including intubation, due to her poor quality of life. The physician documented the decision and placed a DNAR order in the hospital chart. She was subsequently discharged home with no order in force limiting treatment.

Today when she developed trouble breathing at home and passed out, her husband called 911 and insisted that the paramedics intubate her on arrival to their home. The paramedics complied with the request. Now in the ICU, her husband is insisting that she continue to receive aggressive life-sustaining treatment. The patient does not have decisional capacity.

The medical team calls for an ethics consult, requesting support for the continuation of the DNAR.

Sample question 2

What is the underlying ethical standard guiding the HEC analysis of this case?

1. Best Interests
2. Surrogate decision-making
3. Beneficence
4. Substituted judgment

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Sample question 3

What should the HEC do first?

1. Ensure that a DNAR order is in effect so that the patient will not receive inappropriate CPR if she decompensates.
2. Obtain a copy of the advance directive signed during the last admission to justify continuing the DNAR order.
3. Meet with the patient's husband to determine why he objects to the DNAR order.
4. Recommend discontinuation of life-sustaining treatment as the patient did not want to be intubated in the first place.

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Sample question 4

In response to the request for the consult, what should the HEC do?

1. Inform the medical team that an ethics consult is not indicated, as it not required to enforce a legally documented DNAR.
2. Redirect the medical team to the hospital's administration and legal counsel, as they would be more appropriate to lend institutional support the DNAR order.
3. Discuss the reason for an ethics consult with the medical team and set reasonable expectations for the consult.
4. Support the medical team's view that a DNAR is appropriate in this situation and that continuation of life support is inappropriate in this situation.

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Sample question 5

It is not uncommon for providers to become uncomfortable when a patient with capacity refuses to accept what the team perceives to be a safe discharge either to a facility or to home with services, in favor of discharge to the community without recommended safeguards.

What ethics advice should an HEC provide to the healthcare team to address this dilemma?

1. The patient with capacity to participate in discharge decision-making may accept or reject the discharge recommendations offered by the team.
2. The healthcare team should implement its discharge plan over the objection of the patient if the patient lacks relevant decisional capacity.
3. It is not appropriate to honor the discharge preferences of a patient with only limited relevant decisional capacity.
4. Legal or risk management should be involved whenever a patient refuses the recommended discharge plan.

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Sample question 6

A first year neurology resident contacts the HEC with concerns that the family of one of her patients is being pressured by the neurosurgeon to continue aggressive treatment even though the patient's family is worried that the burdens are more than the patient would find acceptable. The resident states, "The nurses and the family are in distress, but everyone is too scared to raise the issue with the neurosurgeon. In fact, I would be afraid for him to know we even talked. Can we keep this between us?" How should the HEC respond?

1. The HEC's responsibility to notify the attending physician of the consult includes informing the attending who made the request.
2. The conversations with the HEC can be confidential if the resident is concerned about retaliation.
3. Best practices discourage the HEC from allowing anonymous requests for consultation because they build a culture of whistleblowing and mistrust.
4. It is part of the primary resident's professional responsibility to speak directly with the attending physician.

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Sample question 7

Moral distress is common when a patient's family members appear to compel providers to deliver treatment upon an incapacitated patient for whom providers assess that treatment to be potentially inappropriate. Which of the following options is the recommended approach for avoiding these "futility disputes"?

1. Help providers recognize that they are free to discontinue intervention that they judge to be potentially inappropriate regardless of the family's demands.
2. Facilitate awareness among providers that a futility dispute should trigger a call to legal affairs, who will likely recommend that the hospital petition the court.
3. Promote advance directives because a very clear living will overrides the family's right to compel interventions.
4. Encourage providers to explain to family members that their duty is to offer and then provide care that is medically indicated for the patient, not just any care that is available.

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Use the following information to answer questions 8–10.

A patient was admitted to the hospital for gangrene on his foot. This is his fifth admission for the same medical problem, and he has left the hospital against medical advice each time to return to homelessness. The vascular surgery team recommends a below-knee amputation, but the patient consistently refuses to consent to the procedure. The attending vascular surgeon states that the situation has become serious and the surgeon is concerned that the patient will risk losing even more of his leg, or even death, without prompt treatment. The nursing team states that the patient is argumentative and often refuses exams, medications, and other routine care.

The HEC goes to the patient's room with the surgeon. The patient is able to state his medical condition without prompting, and he seems to understand his medical problems. When asked about treatment options, he states that surgery is one option and that the proposed amputation is expected to keep him from becoming more ill. When asked what that would mean long term, the patient tells the doctor that he does not want the amputation. He states that he will be better off with his "bum leg" as long as his pain can be controlled. He does not want the surgery because he would not be able to walk through the park.

Sample question 8

What was evaluated in this encounter?

1. Competence to make informed medical decisions
2. Ability to appreciate quality of life considerations
3. Capacity to make informed medical decisions
4. Disclosure of information for the informed consent process

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Sample question 9

After the surgeon steps out of the room, the patient discloses that he is afraid that he will be vulnerable to thieves on the streets if he is unable to walk and is afraid of what will happen to him if he loses his leg. What is the best immediate response?

1. Validate the patient's concerns by engaging in reflective listening and clarify what the patient's goals are for himself.
2. Ask clarifying questions about how the patient has managed to survive the recent weeks of foot pain in order to assess his coping skills.
3. Elicit contact information about any friends or family members who may be able to provide support after discharge from the hospital.
4. Summarize the medical information and offer to set up a meeting with the unit social worker to discuss resources to address his discharge needs.

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Sample question 10

The HEC wants to help convey the patient's fears and goals to the care team in order to implement a plan of care that will address his medical and social needs. What is the BEST approach for facilitating this process?

1. Recommend that the care team request a psychiatric consultation to assess the patient's reasons for refusing treatment.
2. Meet with the patient to ask him who he would want to serve as his surrogate decision maker if his condition declines.
3. Meet with the social worker assigned to the patient's case to discuss how best to provide psychosocial support during this hospitalization.
4. Facilitate a formal meeting with the patient's care team to identify a range of realistic treatment and discharge options by implementing a structured agenda.

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Sample question 11

The HEC at a hospital reviews the last 36 months of consultation records and notices that the majority of consultation requests come from physicians, not from other professionals or from family members. In order to better understand this dynamic, why should the HEC initiate a quality assessment project?

1. To evaluate the accessibility and visibility of ethics consultation
2. To evaluate the structure and staffing of the ethics consultation service
3. To solicit feedback about the expectations and outcomes of ethics consultations
4. To evaluate the efficiency and responsiveness of the ethics consultation service

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Sample question 12

A husband and wife are both patients of the same primary care physician. During his appointment, the husband informs the physician that his wife has been increasingly forgetful and lately has become lost and confused at times when out of the house. She has told her husband that she has not mentioned any such concerns to the physician. The husband asks the physician not to tell the wife he said anything, but to test her for dementia without letting her know why. The provider thinks to himself that the wife has not shown any obvious signs of cognitive impairment in routine encounters.

Which action by the physician is MOST ethically sound?

1. Agree to perform low risk, non-invasive cognitive testing without disclosing the husband's report.
2. Offer to discuss the matter openly with the wife.
3. Tell the husband that the physician is obligated to take his lead from the patient and his plan is to wait until she raises the concern or shows symptoms.
4. Ask the wife more detailed questions than usual about any difficulties with memory or function without providing an explanation.

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Sample question 13

The surgical ICU attending physician calls wanting an ethics consultation regarding a patient who has been in the SICU for 23 days after a kidney transplant with multiple complications and evidence of graft versus host disease. The attending physician explains that the kidney transplant attending physician wants to continue aggressive support for the patient for another week, "even though everyone knows the patient is dying." Assuming that the HEC contacts the kidney transplant attending physician, which of the following potentially relevant interests would be inappropriate for the HEC to raise when they first speak?

1. The kidney transplant attending physician's clinical judgments about the patient's clinical trajectory
2. The kidney transplant attending physician's concerns about the statistics and reputation of the transplant program
3. The kidney transplant attending physician's sense of responsibility about the patient's poor prognosis
4. The kidney transplant attending physician's perception of the HEC services' value to the institution

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