During a visit to her family physician, a 35-year-old woman discloses that she suffers from anorexia nervosa. She complains of fatigue, dizziness, depression, headaches, irregular menses, and environmental allergies. Each day, she uses 15 to 60 laxatives, exercises for several hours, and eats a salad or half a sandwich. At 5'2", she weighs 88 pounds. She demonstrates a good understanding of the diagnosis and the recommended therapy for anorexia. Despite receiving a variety of resource information, the patient refuses any medical intervention.

A middle-aged woman diagnosed with acute myelogenous leukemia has refused chemotherapy for her condition. She is educated, articulate and quite aware that she will certainly die without treatment. She is upset by her diagnosis, but is not depressed. Her close family wishes she would accept treatment because they do not want her to die, but even so, they honor her refusal. She understands that her death will likely be painful and may be prolonged and requests a supply of barbiturates that she might use to take her life when the appropriate time comes.

A recently divorced fifty-five-year-old man with severe rheumatoid arthritis comes in for a routine visit complaining of insomnia. He requests a specific barbiturate, Seconal®, as a sleep aid, asking for a month's supply. On further questioning, he states that he wakes up every morning at four, tired but unable to go back to sleep. He admits that he rarely leaves his house during the day, stating that he has no interest in the activities he used to find enjoyable.

What is an appropriate course of action?

A 5-year-old child has just had his second generalized tonic-clonic seizure in a 4-month period. You have recommended starting an anticonvulsant. The child’s parents have concerns about the recommended medication and would prefer to wait and see if their son has more seizures.

How should you respond to the parents’ request?

An ill-appearing 2-year-old with a fever and stiff neck appears to have meningitis. His parents refuse a lumbar puncture on the grounds that they have heard spinal taps are extremely dangerous and painful.

What are your obligations in this case? How should you proceed?

A 4-year-old with an obviously broken forearm is brought to the emergency department by her baby-sitter. Both the baby-sitter and emergency room staff have attempted to reach her parents without success.

Can you treat this child without parental permission?