On the PANRE-LA topic blueprint, NCCPA lists “Emergent Topics” as 2% of the exam. For many exam takers, these questions are causing headaches due to the lack of clear guidance on what will be covered. NCCPA lists “Legal, Ethical, DEI” on the blueprint, but no one knows the exact questions, and the specifics can’t be shared. Let’s dive a bit deeper into these three topics to help ease your anxiety and prepare you for whatever might come up.
The principles of medical ethics can be used in determining the best course of action when there are conflicting choices. Not only are these principles essential for daily patient care, but they’re also highly testable. Here are the four ethical principles you should know:
If, for example, a question were to be given where autonomy comes in conflict with beneficence, autonomy always wins. Here is an example from our AAPA PANCE/PANRE Qbank demonstrating this:
A 65-year-old patient comes to the clinic to discuss the results of a recent MRI and liver biopsy, which show that they have hepatocellular carcinoma. The results also show that the patient could be a candidate for liver transplantation. The PA recommends liver transplantation and explains that the procedure will give the patient the best chance for long-term survival. The patient says that they are not willing to undergo liver transplantation or systemic chemotherapy, but they are willing to consider other treatment options, if available. This scenario demonstrates which of the following key ethical concepts in patient care?
Answer: Autonomy
In this scenario, the PA believes the best option for long-term survival is surgery. Recommending surgery is an example of acting with beneficence. In this case scenario, it likely provides the best chance of treatment success or cure of the patient’s condition. However, the patient is unwilling to undergo surgery, and their right to autonomy supersedes beneficence in this case.
It is essential to understand the definitions and the concept between two legal terms: living will/advanced directives and durable power of attorney. These both require official signed legal documents.
Here is an example from our AAPA PANCE/PANRE Qbank on how a question about these topics may be asked on an exam.
An 80-year-old woman with a history of dementia is brought to the emergency department from a skilled nursing facility because she has had a fever for the past two days. The patient is nonverbal at baseline due to worsening cognitive dysfunction. Temperature is 39.0°C (102.2°F), pulse rate is 130/min, and blood pressure is 90/40 mmHg. The patient appears ill. Physical examination shows a rigid abdomen. A CT scan of the abdomen with intravenous contrast is recommended, but this requires consent, which the patient is unable to give. Her durable power of attorney for health care is her daughter who is contacted via telephone. After discussing the situation with the daughter, she declines to give consent, saying that her mother’s quality of life is poor and requesting no further diagnostic tests or treatment. The PA makes it clear to the daughter that her mother’s condition is dire, and no further treatment will certainly result in her mother’s death. The daughter acknowledges this information. Which of the following is the most appropriate next step?
Answer: Abide by the daughter’s wishes and discontinue all additional testing or treatment
This question outlines how the daughter’s decisions are to be followed as the patient’s legal durable power of attorney for healthcare, even though the treating PA may disagree with the decision that is being made.
A few other concepts that may get tested on are informed consent and confidentiality with minors. We must always obtain informed consent from our patients, and there are five features of it that need to be reviewed and documented:
If there were to be a test item on confidentiality or needed consent for treatment of minors, we all know that 18 is the age of majority where patients can consent without their parents or guardians, but there are a few exceptions and these concepts are testable.
If a minor is < age 18, parents or guardians need to consent to treatment except in cases of:
Laws may vary by state regarding the age minors are given these rights to consent. As there is some state-by-state variation for age, if a test question were to be asked about this, the patient would most likely be 17 (right under the age of majority), so there isn’t any room to argue the correctness of the information.
Diversity, Equity, and Inclusion (DEI)
“DEI” or Diversity, Equity, and Inclusion is also listed on the NCCPA blueprint. As a prolific item writer for Hippo Education, I would find it challenging to write a test item about a DEI topic that was more than simply a definition of one of these topics. However, I don’t write for NCCPA, so we, as PAs, have to be ready for whatever question they may ask.
NCCPA could potentially ask questions about the proper use of interpreters for non-English speaker patients which could loosely fit under this topic umbrella. The appropriate use of interpreting services again is not only something important to know for clinical practice, but also for the exam.
Here are some testable high points:
Below are the definitions for the pillars of DEI:
While there’s no way to know exactly which topics will be asked under “Emergent Topics” on the PANRE-LA, we hope this primer helps you feel more prepared and eases some of the anxiety surrounding these questions.
For more help with the PANRE-LA, check out our AAPA PANRE-LA Reference Guide!