Ethics in the trenches: Part 2. Case studies of ethical challenges in emergency medicine

Unique ethical issues arise in the practice of emergency medicine, and common ethical problems are often more difficult to address in the emergency department than in other medical settings. This article is Part 2 of the Series "Ethics in the Trenches" and it presents and analyses 2 cases--each dealing with an ethical challenge that emergency physicians are likely to encounter. The first case deals with patient refusal of care. When a patient refuses recommended care, the emergency physician must ensure the patient's decision is informed and that the patient comprehends the implications of his or her choice. The second case deals with patient involvement in criminal activities. Emergency physicians often encounter patients who have engaged in illegal activities. Although certain activities must be reported, physicians should be mindful of their responsibility to protect patient privacy and confidentiality.     

Ethical issues in palliative care

OBJECTIVES: To review important issues that address respect for patient autonomy, beneficnce, non-maleficence, and justice, which are included in communication surrounding the determination of decision-making capacity, informed consent, breaking bad news, and creating shared goals of care. DATA SOURCES: Review articles, and government and organizational reports. CONCLUSION: Palliative care and its proximity to end-of-life care issues frequently raises ethical issues for patients, their families, and the clinicians caring for them. Supporting the identification and honoring the patient's preferences for treatment are central components of ethical behavior. IMPLICATIONS FOR NURSING PRACTICE: Advance care planning provides an important opportunity for respecting patient autonomy and may be helpful when discussing care options surrounding resuscitation, withholding or withdrawal of treatment, or the determination of medical futility.     

Brain resuscitation. Ethical perspectives

Brain resuscitation is the newest in a long line of treatment protocols that is designed to aid us in sustaining not just life, but quality life in the critical care setting. Like other, previously established protocols, it is not value free. Its implementation brings ethical considerations that must be addressed. If the issues are not addressed, there is the real danger that the resulting moral dilemmas will overwhelm the nurse. In brain resuscitation, there are at least three ethical issues that must be recognized. These are the role of resuscitation in the life process, allocation of scarce resources, and participation in research. To address these issues, nurses will have to be aware of the ethical principle and/or perspectives involved. For some of these issues, the solutions will have to come from nursing's national organizations, such as the American Association of Critical Care Nurses. Other solutions presented will require the nurse to come to an individual decision regarding the ethics of brain resuscitation. The journey to the conclusion of this discussion will end with disappointment for those who sought an algorhythm or decision tree with which to make definitive decisions in regard to ethical decisions about brain resuscitation. To have assumed that such an absolute discussion in regard to the ethical perspectives related to brain resuscitation is possible or even desirable would have been to deny the moral/ethical responsibilities of the nurse who practices in a critical care setting. While these ethical responsibilities can be overwhelmingly burdensome, they can also be opportunities. They can be positive opportunities for our health care colleagues, our patients, and ourselves.     

Ethical conflicts in prehospital emergency care

This article analyses and presents a survey of ethical conflicts in prehospital emergency care. The results are based on six focus group interviews with 29 registered nurses and paramedics working in prehospital emergency care at three different locations: a small town, a part of a major city and a sparsely populated area. Ethical conflict was found to arise in 10 different nodes of conflict: the patient/carer relationship, the patient's self-determination, the patient's best interest, the carer's professional ideals, the carer's professional role and self-identity, significant others and bystanders, other care professionals, organizational structure and resource management, societal ideals, and other professionals. It is often argued that prehospital care is unique in comparison with other forms of care. However, in this article we do not find support for the idea that ethical conflicts occurring in prehospital care are unique, even if some may be more common in this context.     

Ethical issues in geriatrics: a guide for clinicians

Because of demographic trends, it is reasonable to expect that clinicians will care for an increasing number of elderly persons with challenging medical and psychosocial problems. These problems and issues, in turn, may lead to daunting ethical dilemmas. Therefore, clinicians should be familiar with ethical dilemmas commonly encountered when caring for elderly patients. We review some of these dilemmas, including ensuring informed consent and confidentiality, determining decision-making capacity, promoting advance care planning and the use of advance directives, surrogate decision making, withdrawing and withholding interventions, using cardiopulmonary resuscitation and do-not-resuscitate orders, responding to requests for interventions, allocating health care resources, and recommending nursing home care. Ethical dilemmas may arise because of poor patient-clinician communication; therefore, we provide practical tips for effective communication. Nevertheless, even in the best circumstances, ethical dilemmas occur. We describe a case-based approach to ethical dilemmas used by the Mayo Clinic Ethics Consultation Service, which begins with a review of the medical indications, patient preferences, quality of life, and contextual features of a given case. This approach enables clinicians to identify and analyze the relevant facts of a case, define the ethical problem, and suggest a solution.     

Assessment of the quality improvement of prehospital emergency care in Sweden.

The optimal competence level of personnel involved in prehospital emergency care is a matter for discussion. In Sweden a national quality improvement process has been initiated including strict regulation of the authorization of ambulance personnel to administer drugs and increased involvement of registered nurses. The aim of the present study was to assess from a national survey the present status of the ongoing quality improvement process in prehospital emergency care in Sweden. A questionnaire, detailing organizational, staffing, competence and functional aspects, was sent to all medical directors of prehospital EMS. The response frequency was 87.5%. Variations in the local organization of the prehospital care were observed. Only a limited number (20%) of the districts organized the ambulance services according to the competence level of the personnel. It was found that the competence level of the personnel involved in prehospital emergency care had improved considerably compared with the situation 5 years ago. A majority of the ambulancemen had increased their competence level by completing nurse assistant training and more registered nurses had been employed. The changes in the competence level and organization of the ambulance services and prehospital emergency care were considered to have had moderate (38.5%) or great (51.9%) impact on the quality of the services during the past 5 years. The effect was reported by 53.2% of the directors to be objectively verified from review of ambulance records, regular proficiency tests, patient survival data (cardiopulmonary resuscitation), and analyses of computer-based records. It is concluded that the present study clearly shows that quality improvement process initiated by the Swedish authorities has resulted in a considerable improvement of prehospital emergency care in Sweden during the past few years.     

Evolution of a home health ethics committee

In 1996, the Visiting Nurse Association of Boston established an Ethics Advisory Committee to address ethical issues that arise in patient care. This article describes the Committee's development from implementation of an ethics education plan for agency staff, to policy recommendations and consultation for ethical conflicts in patient care. Whether developing an ethics committee or evaluating your current one, this article can be helpful.     

Naemsp 1999 annual meeting

The complete and irreversible cessation of life is often difficult to determine with complete confidence in the dynamic environment of out-of-hospital emergency care. As a result, resuscitation efforts often are initiated and maintained by emergency medical services (EMS) providers in many hopeless situations. Medical guidelines are reviewed here to aid EMS organizations with respect to decisions about: 1) initiating or waiving resuscitation efforts; 2) the appropriate duration of resuscitation efforts; and 3) recommended procedures for on-scene or prehospital pronouncement of death (termination of resuscitation). In cases of nontraumatic cardiac arrest, few unassailable criteria, other than certain physical signs of irreversible tissue deterioration, exist for determining medical futility at the initial encounter with the patient. Thus, the general medical recommendation is to attempt to resuscitate all patients, adult or child, in the absence of rigor mortis or dependent lividity. Conversely, well-founded guidelines now are available for decisions regarding termination of resuscitation in such patients once they have received a trial of advanced cardiac life support. In practice, however, the final decision to proceed with on-scene pronouncement of death for these patients may be determined more by family and provider comfort levels and the specific on-scene environment. For patients with posttraumatic circulatory arrest, the type of injury (blunt or penetrating), the presence of vital signs, and the electrocardiographic findings are used to determine the futility of initiating or continuing resuscitation efforts. In general, patients who are asystolic on-scene are candidates for on-scene pronouncement, regardless of mechanism. With a few exceptions, blunt trauma patients with a clearly associated mechanism of lethal injury are generally candidates for immediate cessation of efforts once they lose their pulses and respirations. Regardless of the medical futility criteria, specialized training of EMS providers and targeted related testing of operational issues need to precede field implementation of on-scene pronouncement policies. Such policies also must be modified and adapted for local issues and resources. In addition, although the current determinations of medical futility, as delineated here, are important to establish for societal needs, the individual patient's right to live must be kept in mind always as new medical advances are developed.     

Futile cardiopulmonary resuscitation for the benefit of others: an ethical analysis

It has been reported as an ethical problem within prehospital emergency care that ambulance professionals administer physiologically futile cardiopulmonary resuscitation (CPR) to patients having suffered cardiac arrest to benefit significant others. At the same time it is argued that, under certain circumstances, this is an acceptable moral practice by signalling that everything possible has been done, and enabling the grief of significant others to be properly addressed. Even more general moral reasons have been used to morally legitimize the use of futile CPR: That significant others are a type of patient with medical or care needs that should be addressed, that the interest of significant others should be weighed into what to do and given an equal standing together with patient interests, and that significant others could be benefited by care professionals unless it goes against the explicit wants of the patient. In this article we explore these arguments and argue that the support for providing physiologically futile CPR in the prehospital context fails. Instead, the strategy of ambulance professionals in the case of a sudden death should be to focus on the relevant care needs of the significant others and provide support, arrange for a peaceful environment and administer acute grief counselling at the scene, which might call for a developed competency within this field.     

Ethical issues for nurses providing perinatal care in community settings

Ethical issues in perinatal nursing are complex in that two patients--mother and fetus--are considered. This work considers six areas of potential ethical conflict: conflict between the mother and fetus, informed consent, confidentiality, cultural conflicts, conflicts associated with managed care, and conflicts in childbirth education. Ethical principles of autonomy, beneficence, and justice are included. Strategies for resolving ethical conflicts in community practice settings are suggested.     

专职化院前急救对心肺复苏成功率的影响

目的探讨专职化院前急救对心肺复苏成功率的影响。方法135例院前心肺复苏患者的资料,按非专职化院前急救与专职化院前急救两种情况进行分组,从医务人员状况、出车时间、到达现场时间、院前应用高级生命支持技术(ACLS)技术及抢救成功率等方面进行对比研究。结果专职化院前急救心肺复苏成功率达26.8%,较非专职化成功率3.7%有显著的提高(P<0.05),且出车时间、到达现场时间、车载设备的配备、现场应用高级生命支持技术等均有明显的改善。结论专职化院前急救可提高院前心肺复苏的成功率。     

Mass casualty incident. Integration with prehospital care

Mass casualty incident involves the use of limited resources for multiple casualties. The emergency physician must be familiar with both prehospital and hospital plans for mass casualty care in order to facilitate optimal care and to maintain the continuum from field care to definitive treatment. It is essential that the emergency physician become involved in the disaster planning processes to ensure that the victims receive the best care available under the circumstances and that the safety and emotional well-being of both prehospital and hospital personnel are assured. Emergency physicians involved in prehospital care should be certain that the local EMS system has adequate training and chances to update their skills and knowledge. Disaster drills of the EMS system are excellent ways to practice, to identify weaknesses, and for preplanning to enhance disaster medical care.     

C ARDIAC A RREST M ANAGEMENT

Approximately 1,000 people in the United States suffer cardiac arrest each day, most often as a complication of acute myocardial infarction (AMI) with accompanying ventricular fibrillation or unstable ventricular tachycardia. Increasing the number of patients who survive cardiac arrest and minimizing the clinical sequelae associated with cardiac arrest in those who do survive are the objectives of emergency medical personnel. In 1990, the American Heart Association (AHA) suggested the chain of survival concept, with four links—early access, cardiopulmonary resuscitation (CPR), defibrillation, and advanced care—as the way to approach cardiac arrest. The recently published International Resuscitation Guidelines 2000 of the AHA have addressed advances in our understanding of the chain of survival. While the chain of survival concept has withstood a decade of scrutiny, there are only a few scientifically rigorous research studies that support changes in prehospital patient care. Additional research efforts carried out in the prehospital setting are needed to support the concepts included in the chain of survival for cardiac arrest patients. Participants at the second Turtle Creek Conference, a meeting of experts in the field of emergency medicine held in Dallas, Texas, on March 29–31, 2000, discussed these and other issues associated with prehospital emergency care in the cardiac arrest patient. This paper addresses a number of the issues associated with each of the links of the chain of survival, the evidence that exists, and what should be done to achieve the clinical evidence needed for true clinical significance. Also included in this paper are the consensus statements developed from small discussion groups held after the main presentation. These comments provide another perspective to the problems and to possible approaches to deal with them.     

An Open,Interoperable, and Scalable Prehospital Information Technology Network Architecture

Abstract

Some of the most intractable challenges in prehospital medicine include response time optimization, inefficiencies at the emergency medical services (EMS)–emergency department (ED) interface, and the ability to correlate field interventions with patient outcomes. Information technology (IT) can address these and other concerns by ensuring that system and patient information is received when and where it is needed, is fully integrated with prior and subsequent patient information, and is securely archived. Some EMS agencies have begun adopting information technologies, such as wireless transmission of 12-lead electrocardiograms, but few agencies have developed a comprehensive plan for management of their prehospital information and integration with other electronic medical records. This perspective article highlights the challenges and limitations of integrating IT elements without a strategic plan, and proposes an open, interoperable, and scalable prehospital information technology (PHIT) architecture. The two core components of this PHIT architecture are 1) routers with broadband network connectivity to share data between ambulance devices and EMS system information services and 2) an electronic patient care report to organize and archive all electronic prehospital data. To successfully implement this comprehensive PHIT architecture, data and technology requirements must be based on best available evidence, and the system must adhere to health data standards as well as privacy and security regulations. Recent federal legislation prioritizing health information technology may position federal agencies to help design and fund PHIT architectures.     

Principles of Clinical Ethics and Their Application to Practice

An overview of ethics and clinical ethics is presented in this review. The 4 main ethical principles, that is beneficence, nonmaleficence, autonomy, and justice, are defined and explained. Informed consent, truth-telling, and confidentiality spring from the principle of autonomy, and each of them is discussed. In patient care situations, not infrequently, there are conflicts between ethical principles (especially between beneficence and autonomy). A four-pronged systematic approach to ethical problem-solving and several illustrative cases of conflicts are presented. Comments following the cases highlight the ethical principles involved and clarify the resolution of these conflicts. A model for patient care, with caring as its central element, that integrates ethical aspects (intertwined with professionalism) with clinical and technical expertise desired of a physician is illustrated.     

Developing EMS quality assessment indicators

An emergency medical service (EMS) system is part of a broad health care system which no longer can be concerned exclusively with patient transportation. Integration of prehospital and in-hospital emergency care must be achieved to provide quality patient care. This article suggests modifications in the Joint Commission on Accreditation of Healthcare Organization's (JCAHO) 10-Step Model indicators that should help in an evaluation of the issues associated with the diversion of patients from Emergency Departments. The JCAHO model is one that can be used to help integrate prehospital and inhospital care.     

The ethical attitude of emergency physicians toward resuscitation in Korea

This study was conducted to assess the various ethical attitudes of emergency specialists in Korea toward resuscitation. A questionnaire investigating the following key topics concerning the ethics of resuscitation was sent to emergency specialists in Korea: when not to attempt resuscitation, when to stop resuscitation, withdrawal of life-sustaining treatment, diagnosis of death by non-physicians, permission for family members to stay with the patient during resuscitation, and teaching with the body of the recently deceased patient. We found broad variation in medical practice at patient death and in the ethical considerations held and followed by emergency physicians (EPs) during resuscitation in Korea. Initiating and concluding resuscitation attempts were practiced according to ethical and cultural norms, as well as medical conditions. Guidelines for resuscitation ethics that are based on the Korean medico-legal background need to be developed. Education of EPs to solve the ethical dilemma in resuscitation is needed.     

Principles of prehospital care of musculoskeletal injuries

Prehospital management of musculoskeletal injuries in the traumatized patient is based on the application of a few basic principles in an orderly but expeditious manner. The patient must be assessed for immediate life-threatening conditions involving airway, respiratory, and circulatory functions while the cervical spine is protected. Resuscitative efforts to reestablish and preserve an adequate circulating volume of oxygenated blood must follow, using airways, oxygen therapy, and fluid replacement through MAST trousers and intravenous fluids. Cardiac function must be maintained as well. Respiratory function must be monitored and assisted as required. Finally, neurologic status must be assessed and monitored. Secondary assessment of all pertinent history and physical findings is made to delineate all other injuries that do not pose an immediate threat to the life or limb of the patient. Definitive care follows but is limited to basic resuscitation, stabilization, and immobilization techniques under medical control through telemetry and radio communication. Immediate definitive care of the traumatized patient requires the expeditious intervention of the trauma team in a hospital setting with surgical, blood banking, radiographic, laboratory, and other hospital-based capabilities available. Field management of the traumatized patient is directed at the expeditious delivery of the viable patient to the trauma team. In the multiply traumatized patient with severe injuries to several organ systems, prehospital care may need to be expedited to provide this patient the in-hospital care required to save his or her life. Appropriate treatment in such life-threatening trauma situations will consist of a rapid primary assessment, airway and cervical spine control, appropriate respiratory and cardiovascular assistance, gross whole body fracture immobilization using a backboard, and immediate transport. For less severely injured patients, primary assessment, resuscitation, stabilization, full secondary assessment, initial definitive care, and immobilization should be completed before transport begins.     

His and hers abdominal pain

Abdominal pain should not be dismissed without proper evaluation. A patient presenting with acute, severe abdominal pain is best transported to the emergency room for treatment. While gender issues remain a delicate subject, proper prehospital care prevents patient deterioration, tissue loss and loss of life. Prehospital information is invaluable. Due to unforeseen complications, including patient deterioration, the history you obtain on scene may be the only information available to the medical team at the hospital. Professional care begins in the prehospital setting. Knowledge, skill and experience will guide you.