A 67-year-old woman is diagnosed with breast cancer. She is fully alert and very specifically both verbally and in writing tells you that she does not want to have surgery on her breast to remove the tumor. She fully understands her condition and treatment options. This is a decision her husband and son both disagree with. Over the next several weeks the patient becomes confused and loses the capacity to understand the details of her medical care. The husband and son now approach you to perform the surgery. Which of the following is most appropriate?

A 67-year-old woman is diagnosed with breast cancer. She is fully alert and very specifically both verbally and in writing tells you that she does not want to have surgery on her breast to remove the tumor. She fully understands her condition and treatment options. This is a decision her husband and son both disagree with. Over the next several weeks the patient becomes confused and loses the capacity to understand the details of her medical care. The husband and son now approach you to perform the surgery. Which of the following is most appropriate?

A 79-year-old man comes to see you for assistance in ending his life. The patient is fully competent and has been suffering from progressively worsening amyotrophic lateral sclerosis for several years. He is not immediately preterminal. Despite this, he finds his quality of life to be unacceptable. More important, he correctly predicts that his level of function will deteriorate over the next several months and that he may become ventilator dependent. He is requesting that you administer a lethal injection in his home. He is not depressed. His family is aware of his desire and they are willing to honor the patient's wishes. You have discussed appropriate palliative care issues. What should you tell him?

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?

A 45-year-old man is brought to the emergency department following a serious motor vehicle collision on a California interstate highway. Despite all attempts to save him, his condition does not improve. The physician caring for him believes that he is brain dead. On examination, the patient's temperature is $36.7 \mathrm{C}(98 \mathrm{~F})$ and blood pressure is $104 / 60 \mathrm{~mm} \mathrm{Hg}$. He is on mechanical ventilation. Neurologic examination is consistent with brain death. Laboratory and imaging studies are not suggestive of a reversible cause. Apnea testing shows no spontaneous breathing. In accordance with local regulations, a second physician confirms the diagnosis of brain death. The patient's family understands the prognosis. Unfortunately, the patient does not have an advanced directive or durable medical power of attorney. Which of the following steps is legally necessary to remove this patient from the ventilator?

An unconscious 42-year-old man is brought to the emergency department by ambulance after sustaining a gunshot wound to the chest during an attempted robbery at a convenience store. He is bleeding profusely. The patient is minimally responsive to pain and is unable to provide any history. The ambulance record indicates that his initial blood pressure was $120 / 70 \mathrm{~mm} \mathrm{Hg}$, pulse was $95 / \mathrm{min}$, and respirations were $16 / \mathrm{min}$. The patient's current blood pressure is $70 / 40 \mathrm{~mm} \mathrm{Hg}$, pulse is $130 / \mathrm{min}$, and respirations are $28 / \mathrm{min}$. He has an open gunshot wound in the chest and an exit wound in the back. Intravenous fluids and vasopressors are started, and a blood transfusion is ordered. The patient's fiance arrives and states that he should not receive a blood transfusion because he is a devout Jehovah's Witness. No evidence is found in the medical chart of advance directives or a living will documenting the patient's wishes and examination of his belongings show no blood refusal card. Which of the following is the most appropriate next step in management of this patient?