Study guide
17.2 Informed Consent, Treatment Refusal & Special Scenarios
ABIM Internal Medicine Exam
Track your progress as you read
Finished sections get a check mark.
1 Chapter 0: The ABIM Exam, Blueprint & Study Strategy
0.1 Exam Format, Question Types & the 2026 Blueprint 0.2 Eligibility, Registration, Fees & Exam-Day Logistics 0.3 Scoring, the Passing Standard & Score Reports 0.4 Building a Blueprint-Weighted Study Plan
2 Chapter 1: Cardiovascular Disease (14% of Exam)
1.1 Ischemic Heart Disease & Acute Coronary Syndromes 1.2 Antithrombotic Therapy, Secondary Prevention & Mechanical Complications of MI 1.3 Atrial Fibrillation, Atrial Flutter & Stroke Prevention 1.4 Supraventricular Tachycardias, Ventricular Arrhythmias & Bradycardias 1.5 Heart Failure: Classification, Staging & Guideline-Directed Medical Therapy 1.6 Device Therapy, HFpEF & the Cardiomyopathies 1.7 Valvular Heart Disease & Endocarditis Prophylaxis 1.8 Pericardial Disease & Acute Aortic Syndromes 1.9 Hypertension: Classification, Diagnosis & Secondary Causes 1.10 Hypertensive Crises & Dyslipidemia 1.11 Adult Congenital Heart Disease & Coarctation of the Aorta 1.12 Syncope: Reflex, Orthostatic & Cardiac Causes 1.13 Cardiac Physical Examination, Murmurs & Antithrombotic Selection
3 Chapter 2: Endocrinology, Diabetes & Metabolism (9% of Exam)
2.1 Diabetes Mellitus: Diagnosis, Glycemic Targets & Pharmacotherapy 2.2 Insulin Therapy, Hyperglycemic Emergencies & Chronic Complications 2.3 Thyroid Function Testing & Hypothyroidism 2.4 Thyrotoxicosis, Thyroid Storm & Thyroid Nodules 2.5 Adrenal & Pituitary Disorders 2.6 Hypercalcemia, Hypocalcemia & Disorders of Mineral Metabolism 2.7 Osteoporosis & Paget Disease of Bone 2.8 Ovarian, Testicular & Reproductive Endocrine Disorders 2.9 Hypoglycemia, Endocrine Tumors, Polyglandular Syndromes & Severe Hypertriglyceridemia
4 Chapter 3: Gastroenterology & Hepatology (9% of Exam)
3.1 Esophageal Disease 3.2 Stomach & Duodenal Disease and Gastrointestinal Hemorrhage 3.3 Inflammatory Bowel Disease 3.4 Celiac Disease & Irritable Bowel Syndrome 3.5 Diverticular Disease & Colorectal Cancer Screening 3.6 Viral Hepatitis, Steatotic & Alcohol-Associated Liver Disease 3.7 Cirrhosis & the Complications of Portal Hypertension 3.8 Acute Pancreatitis 3.9 Chronic Pancreatitis & Biliary Tract Disease 3.10 Inherited, Autoimmune & Drug-Induced Liver Disease 3.11 Small Intestinal Disease, Ischemia & Gastrointestinal Complications of HIV
5 Chapter 4: Infectious Disease (9% of Exam)
4.1 Lower Respiratory Tract Infections & Sepsis Syndromes 4.2 Viral Respiratory Pathogens & Tuberculosis 4.3 Central Nervous System Infections 4.4 Skin, Soft Tissue, Bone & Joint Infections 4.5 Infective Endocarditis & Cardiovascular Infection 4.6 Clostridioides difficile & Catheter-Related Bloodstream Infection 4.7 HIV Diagnosis, Antiretroviral Therapy & Prevention 4.8 Opportunistic Infections & Sexually Transmitted Infections 4.9 Fever of Unknown Origin, Neutropenic Fever & Toxic Shock 4.10 Travel-Related Illness, Vector-Borne Disease & Outbreaks 4.11 Infection Prevention, Nosocomial Infection & Postexposure Prophylaxis 4.12 Rheumatic Fever, Poststreptococcal Disease, Enteric & Hepatic Infections
6 Chapter 5: Pulmonary Disease (9% of Exam)
5.1 COPD: Diagnosis, GOLD Classification & Initial Pharmacotherapy 5.2 Interventions That Reduce COPD Mortality & Exacerbation Management 5.3 Asthma: Diagnosis, Stepwise Therapy & Status Asthmaticus 5.4 Interstitial Lung Disease & Idiopathic Pulmonary Fibrosis 5.5 Sarcoidosis, Hypersensitivity Pneumonitis & Occupational Lung Disease 5.6 Pulmonary Embolism: Diagnosis, Risk Stratification & Anticoagulation 5.7 Pulmonary Hypertension & Sleep-Disordered Breathing 5.8 Acute Respiratory Distress Syndrome & Mechanical Ventilation 5.9 Pleural Disease, Empyema & Pneumothorax 5.10 Bronchiectasis, Cystic Fibrosis & Restrictive Lung Disease 5.11 Evaluation of Cough, Dyspnea, Hemoptysis & the Solitary Pulmonary Nodule
7 Chapter 6: Rheumatology & Orthopedics (9% of Exam)
6.1 Rheumatoid Arthritis: Diagnosis & Systemic Manifestations 6.2 Antirheumatic Pharmacotherapy & the Spondyloarthropathies 6.3 Gout: Pathophysiology & Acute Management 6.4 Urate-Lowering Therapy & Calcium Pyrophosphate Deposition Disease 6.5 Osteoarthritis 6.6 Systemic Lupus Erythematosus 6.7 Systemic Sclerosis, Sjogren Syndrome & Inflammatory Myopathies 6.8 The Vasculitides 6.9 Regional Musculoskeletal Syndromes, Back Pain & Sports Injuries 6.10 Other Primary Rheumatic Disorders & Mixed Connective Tissue Disease 6.11 Osteonecrosis & Metabolic Bone Disease
8 Chapter 7: Hematology (6% of Exam)
7.1 Approach to Anemia & the Microcytic Anemias 7.2 Macrocytic, Normocytic & Hemolytic Anemias 7.3 Hemoglobinopathies, Thalassemias & Paroxysmal Nocturnal Hemoglobinuria 7.4 Platelet Disorders, Thrombocytopenia & the Bleeding Patient 7.5 Coagulation Factor Disorders, Thrombophilia & Anticoagulant Reversal 7.6 Acute Leukemias, Chronic Leukemias & Myeloproliferative Neoplasms 7.7 Lymphomas & Plasma Cell Disorders 7.8 Myelodysplastic Syndrome, Myeloproliferative Neoplasms & Porphyria 7.9 Transfusion Medicine & Late Complications of Transplantation
9 Chapter 8: Medical Oncology (6% of Exam)
8.1 Breast, Lung, Colorectal & Prostate Cancer 8.2 Oncologic Emergencies 8.3 Genitourinary & Gynecologic Malignancies 8.4 Head and Neck, Bone & Soft Tissue Cancer and Cancer of Unknown Primary 8.5 Complications of Cancer & Its Treatment 8.6 Cancer Prevention, Survivorship & Psychosocial Care
10 Chapter 9: Nephrology & Urology (6% of Exam)
9.1 Acute Kidney Injury: Staging, Etiology & Urine Microscopy 9.2 Glomerular Disorders & Nephrotic Syndrome 9.3 Nephritic Syndromes, RPGN & Indications for Renal Replacement Therapy 9.4 Chronic Kidney Disease: Staging & Progression Retardation 9.5 Complications of Chronic Kidney Disease: Anemia, CKD-MBD & Acidosis 9.6 Hyponatremia, Hypernatremia & Water Balance 9.7 Potassium Disorders & Systematic Acid-Base Analysis 9.8 Renal Tubular Acidosis & Nephrolithiasis 9.9 Prostate Disorders, Urinary Incontinence & Other Urologic Conditions 9.10 Cystic Kidney Disease, Obstructive Uropathy, Tubulointerstitial Disease & Hematuria
11 Chapter 10: Neurology (4% of Exam)
10.1 Acute Ischemic Stroke: Syndromes & Reperfusion 10.2 Transient Ischemic Attack, Secondary Prevention & Hemorrhagic Stroke 10.3 Headache & Facial Pain 10.4 Seizures, Epilepsy & Movement Disorders 10.5 Multiple Sclerosis & Neuromuscular Junction Disorders 10.6 Motor Neuron Disease & Acute Peripheral Neuropathy 10.7 Cranial Neuropathies & Neuro-Ophthalmology 10.8 Peripheral Neuropathies, CNS Tumors & Other Neurologic Disorders
12 Chapter 11: Psychiatry & Behavioral Health (4% of Exam)
11.1 Major Depressive Disorder & Medical Mimics 11.2 Antidepressant Pharmacotherapy & Treatment-Resistant Depression 11.3 Bipolar Disorder, Mood Stabilizers & Lithium Toxicity 11.4 Anxiety, Stress-Related & Obsessive-Compulsive Disorders 11.5 Alcohol Use Disorder & Withdrawal 11.6 Pharmacotherapy for Alcohol & Opioid Use Disorder 11.7 Toxidromes, Psychiatric Emergencies & Suicide Risk Assessment 11.8 Psychotic, Somatic Symptom, Factitious & Personality Disorders 11.9 Eating Disorders, Sleep Disorders & Sexual Health
13 Chapter 12: Dermatology (3% of Exam)
12.1 Dermatitis, Papulosquamous & Inflammatory Dermatoses 12.2 Acne, Rosacea & Cutaneous Infections 12.3 Herpes Zoster & Autoimmune Blistering Diseases 12.4 Nodules, Tumors & Cutaneous Oncology 12.5 Dermatologic Emergencies & Severe Cutaneous Adverse Reactions 12.6 Pigment Disorders, Alopecia, Nail Disease & Photosensitivity 12.7 Vascular Dermatoses, Environmental Injury & Cutaneous Signs of Systemic Disease
14 Chapter 13: Obstetrics & Gynecology / Women's Health (3% of Exam)
13.1 Contraception, Preconception Care & Teratogenicity 13.2 Hypertensive Disorders of Pregnancy & Gestational Diabetes 13.3 Thyroid Disease & Venous Thromboembolism in Pregnancy 13.4 Menopause & Menopausal Hormone Therapy 13.5 Abnormal Uterine Bleeding, Endometrial Disease & Gynecologic Cancer Screening 13.6 Breast Disorders & Diseases of the Vulva and Vagina 13.7 Menstrual Disorders, Fibroids, Endometriosis & Early Pregnancy Complications
15 Chapter 14: Geriatric Syndromes (3% of Exam)
14.1 Comprehensive Geriatric Assessment & Frailty 14.2 Falls, Gait Assessment & Polypharmacy 14.3 Urinary Incontinence & Pressure Injuries in Older Adults 14.4 Mild Cognitive Impairment, Dementia & Its Subtypes 14.5 Delirium & the Pharmacotherapy of Cognitive Disorders 14.6 Palliative Care, Hospice & Advance Care Planning 14.7 Chronic Wounds, Nutrition, Swallowing, Constipation & Hip Fracture 14.8 Sensory Impairment, Dizziness, Elder Mistreatment & Care Settings
16 Chapter 15: Allergy & Immunology (2% of Exam)
15.1 Anaphylaxis: Recognition & Emergency Management 15.2 Urticaria & Angioedema 15.3 Drug Allergy, Desensitization & Adult Immunodeficiency 15.4 Food Allergy, Insect Venom Hypersensitivity, Serum Sickness & Contrast Reactions 15.5 Rhinitis, Conjunctivitis, Eosinophilic & Mast Cell Disorders
17 Chapter 16: Preventive Medicine, Immunization & Clinical Epidemiology
16.1 The USPSTF Framework & Evidence-Based Cancer Screening 16.2 Cardiovascular & Metabolic Screening and Primary Prevention 16.3 Adult Immunization & Vaccines in Special Populations 16.4 Clinical Epidemiology, Biostatistics & Study Design
18 Chapter 17: Miscellaneous - Ethics, Patient Safety & Quality Improvement (2% of Exam)
17.1 Principles of Bioethics & Decisional Capacity 17.2 Informed Consent, Treatment Refusal & Special Scenarios 17.3 Surrogate Decision-Making, Advance Directives & Confidentiality 17.4 Patient Safety Science, Medical Error & Diagnostic Reasoning 17.5 Quality Improvement Methods, Health Disparities & Health Equity
19 Chapter 18: Perioperative Medicine & Medical Consultation
18.1 Preoperative Cardiovascular Risk Assessment 18.2 Preoperative Pulmonary Risk & Perioperative Medication Management 18.3 Perioperative Anticoagulation, Bridging & Postoperative Complications
20 Chapter 19: Ophthalmology (1% of Exam)
19.1 The Acute Red Eye & Ophthalmic Emergencies 19.2 Painless Vision Loss & Chronic Ophthalmic Disease 19.3 Uveitis, Scleritis & Orbital Disease
21 Chapter 20: Otolaryngology & Dental Medicine (1% of Exam)
20.1 Dizziness, Vertigo & Epistaxis 20.2 Ear Disorders, Hearing Loss & Upper Respiratory Infections 20.3 Oral Cavity, Salivary Gland, Laryngeal & Taste and Smell Disorders
17.2 Informed Consent, Treatment Refusal & Special Scenarios
Key Takeaways Explain This Topic AI
Valid informed consent requires disclosure of diagnosis, nature and purpose of treatment, risks, benefits and alternatives including no treatment.
A patient with decision-making capacity may refuse any treatment, including life-sustaining treatment, even when refusal will result in death.
Emergency treatment of a minor to prevent death or serious harm proceeds under implied consent when a parent refuses.
Recognized exceptions to informed consent include emergencies, waiver by the patient and legally authorized public health mandates.
Adolescents may consent independently for care in defined categories such as sexually transmitted infection, contraception and substance use treatment in most jurisdictions.
Last updated: August 2026
D. Medical Conditions Affecting Capacity
Delirium: The most common cause of acute fluctuating capacity in hospitalized patients. Capacity may be present during lucid morning intervals and absent during evening sundowning. Clinicians should aggressively identify and correct underlying triggers (hypoxemia, sepsis, electrolyte abnormalities, urinary retention, anticholinergic medications, opioid toxicity) and re-evaluate capacity once delirium clears. In emergencies before clearance, surrogate or implied consent applies.
Dementia: Mild-to-moderate dementia does not automatically strip a patient of capacity. A patient with early Alzheimer disease may lack capacity to manage complex finances or chemotherapy regimens but retain full capacity to designate a healthcare proxy or decide on a non-invasive treatment.
Psychosis & Psychiatric Illness: The presence of a formal psychiatric diagnosis (e.g., schizophrenia, bipolar disorder, severe major depressive disorder) does NOT equate to incapacity. An individual with chronic auditory hallucinations or active depression retains decision-making capacity unless active psychotic delusions or affective distortion directly hijack their understanding, appreciation, or reasoning regarding the specific medical intervention.
Substance Intoxication & Withdrawal: Acute alcohol, sedative, or stimulant intoxication transiently impairs cognitive faculties. If non-emergent, defer decisions until sobriety is achieved. In acute trauma or shock, manage under the emergency exception until sober.
- 1. Informed Consent, Treatment Refusal & Special Clinical Scenarios
- A. Essential Requirements of Informed Consent
Informed consent is an ethical and legal communication process, not merely a signed piece of paper. A valid consent dialogue requires four mandatory elements:
Decisional Capacity: The patient must have verified capacity for the specific intervention.
Adequate Disclosure: The physician must explain:
- The patient's underlying diagnosis and clinical condition,
- The nature, purpose, and technical details of the proposed intervention,
- Substantial, material, and common risks of the procedure,
- Expected clinical benefits and success rates,
- Reasonable alternative diagnostic or therapeutic options (including off-label uses),
The natural history and risks of no treatment / refusal .
Comprehension: The patient must understand the information in their preferred language.
Voluntariness: The decision must be made freely, without coercion, threats, or undue institutional pressure.
B. Exceptions to Informed Consent
There are only three legitimate legal exceptions to the requirement for explicit informed consent:
Emergency Exception (Implied Consent): Applies when an acute, life- or limb-threatening clinical condition exists, the patient lacks decisional capacity (e.g., coma, severe trauma, cardiac arrest), no surrogate decision-maker is immediately contactable, and immediate intervention is required to prevent death or permanent severe disability. Consent is legally implied under the presumption that a reasonable person would desire life-saving care.
Patient Waiver: A competent patient explicitly, voluntarily, and knowingly waives their right to receive clinical details and requests that the physician or designated family members make all medical decisions on their behalf.
Therapeutic Privilege: An extremely narrow, rarely justified legal exception where a physician withholds clinical diagnostic or prognostic information because direct disclosure would inflict immediate, profound, and severe psychological devastation (e.g., precipitating acute suicidality or catastrophic psychosis). Therapeutic privilege does NOT apply simply because the news is upsetting, stressful, sad, or feared to cause refusal of care.
C. Patient Autonomy & Refusal of Life-Sustaining Treatment
An adult patient with demonstrable decision-making capacity possesses the absolute ethical and legal right to refuse ANY medical intervention , including life-sustaining therapy (mechanical ventilation, hemodialysis, total parenteral nutrition, inotropes, blood transfusions, or cardiopulmonary resuscitation).
Physician Obligations during Refusal:
Thoroughly evaluate and document decision-making capacity under high-stakes sliding-scale scrutiny.
Explore the patient's underlying reasoning, fears, misconceptions, and personal values without confrontation.
Clearly disclose the specific consequences of refusal (including permanent organ failure, pain, and death).
Offer alternative supportive, palliative, or symptom-directed therapies (e.g., hospice care, aggressive dyspnea management with opioids and benzodiazepines).
D. Refusal of Blood Transfusions by Jehovah's Witnesses
Jehovah's Witness doctrine prohibits the ingestion or intravenous administration of whole blood and major blood fractions (red blood cells, white blood cells, platelets, and plasma) based on biblical passages (e.g., Genesis 9:4, Leviticus 17:10, Acts 15:29).
Clinical Context Legal & Ethical Standard Practical Clinical Management Protocol
Competent Adult Absolute right to refuse all blood transfusions, even when refusal results in fatal hemorrhagic shock. 1. Interview patient privately without family or church elders present to ensure refusal is voluntary and free from coercion.; 2. Assess decision-making capacity and document refusal rigorously.; 3. Explore acceptance of specific non-prohibited fractionated blood components and blood-sparing technologies.; 4. Optimize bloodless medicine protocols (IV iron, erythropoietin, tranexamic acid, cell salvage).
Incapacitated Adult with Valid Directive Must honor documented refusal (e.g., signed advance directive or durable Power of Attorney card). Verify that the advance directive or wallet card is authentic, signed, and explicitly states refusal of blood products in life-threatening circumstances. Do not transfuse.
Minor Children (Pediatric Patients) Parents do NOT have the legal or ethical right to refuse life-saving medical therapy or martyr their children. If a minor child of Jehovah's Witness parents suffers life-threatening anemia or hemorrhage:; 1. The physician MUST administer life-saving blood products immediately .; 2. Simultaneously notify hospital risk management and obtain an emergency court order / protective custody under the state's parens patriae authority ( Prince v. Massachusetts ).
Pregnant Patient Competent pregnant women retain autonomous rights; fetal viability rules vary by state jurisdiction. Assess capacity privately. If pre-viable, maternal refusal governs. If viable, emergent ethics and legal consultation is mandatory; maternal autonomy remains strongly protected in modern jurisprudence.
Blood-Sparing & Alternative Medical Strategies for Jehovah's Witness Patients:
Recombinant Human Erythropoietin (EPO): 20,000–40,000 units subcutaneously 3 times weekly to stimulate erythropoiesis.
Intravenous Iron: Ferric derisomaltose (1000 mg IV) or Iron sucrose (200 mg IV) to accelerate hemoglobin recovery.
Antifibrinolytic Agents: Tranexamic acid (1 g IV loading dose over 10 min followed by 1 g infusion over 8 hours in acute trauma/hemorrhage).
Intraoperative Blood Salvage (Cell Saver): Many Jehovah's Witness patients accept cell salvage if maintained in a continuous closed-circuit loop that remains in unbroken contact with the patient's circulatory system.
Acceptable Fractionated Products (Variable by Individual): Albumin, clotting factor concentrates (Factor VIIa, Prothrombin Complex Concentrates [PCC], fibrinogen concentrate), immune globulins.