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Difficulty: MediumProfessionalism and Workplace Ethics

An intern is working on an internal medicine ward under the supervision of a senior resident. They are managing a 78-year-old man who is unresponsive following a severe ischemic stroke. The patient has a legally appointed healthcare proxy, his daughter, who is currently flying in from another state. The patient also has a complicated urinary tract infection; urine culture and sensitivity results just returned, indicating that the pathogen is susceptible only to a specific narrow-spectrum antibiotic.

The senior resident, who appears exhausted at the end of a 24-hour shift, tells the intern: "Just keep him on the broad-spectrum antibiotics, it is easier than changing the orders. Also, his wife is at the bedside right now—just have her sign the consent for the feeding tube so we can get the procedure scheduled." The resident then steps into the busy main hallway and loudly complains, "These families always take forever to make end-of-life decisions; they are wasting our resources."

The intern recognizes that the resident's instructions and conduct are inappropriate. Which of the following is the most appropriate next step for the intern?

  1. Escalate the concerns regarding the resident's clinical directives and behavior to the attending physician.Answer
  2. B
    Request that the patient's wife provide informed consent, as she is the immediate next-of-kin present at the bedside.
  3. C
    Maintain the broad-spectrum antibiotics to ensure the patient receives continuous coverage and to avoid hierarchical conflict.
  4. D
    Consult with an unaffiliated physician friend in a public area regarding the patient's detailed clinical scenario to determine the best course of action.
  5. E
    Initiate a punitive disciplinary report against the resident rather than engaging in a root cause analysis of the fatigue-related error.

Answer

Escalate the concerns regarding the resident's clinical directives and behavior to the attending physician.
The correct answer is to escalate the concerns to the attending physician. When a superior gives directives that compromise patient safety (e.g., inappropriate antibiotic use) or violate ethical/legal standards (e.g., bypassing a legally appointed healthcare proxy), a subordinate physician is professionally obligated to intervene. The intern must not execute the harmful orders and must report the situation to the attending physician, who is ultimately responsible for both patient care and the management of team dynamics.

Step-by-Step Solution

1
Identify the multiple ethical and patient safety violations in the resident's directives.
The resident is asking the intern to bypass the legal surrogate, ignore antibiotic stewardship, and is breaching professionalism/confidentiality in the hallway.
Recognizing unsafe and unethical orders is the first step in protecting the patient.
2
Determine the intern's responsibility in the hierarchical chain of command.
The intern must refuse to carry out the harmful orders.
Subordinates are not absolved of ethical and clinical responsibility simply because an order came from a superior.
3
Select the most appropriate channel for reporting.
The intern should escalate the issue to the attending physician.
The attending physician bears ultimate responsibility for the patient's care and the educational supervision of the resident team.

Key Concept

Professionalism, Hierarchy, and Patient Safety
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Topics

Professionalism and Workplace Ethics

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