virtual class room excercise

Chapter 15

Bioethical Dilemmas in Emergency Medicine and Pre-

Hospital Care

3

Key Ethical Issues for Emergency Practitioners

• Continue to care for the critically ill and injured while also acting as a medical safety net for the medically indigent;

• Aggressively treat critical patients and yet avoid paternalism toward those who can participate in their own health care decisions;

• Preserve patient autonomy while implementing prehospital advance directives;

4

Key Ethical Issues for Emergency Practitioners

• Respond to failed physician-assisted suicides (PAS);

• Break bad news and provide end-of-life care; • Evaluate patients’ decision-making capacity

and work with surrogate decision makers; • Keep emergency medical providers safe while

caring for patients;

5

Key Ethical Issues for Emergency Practitioners

• Approach triage/disasters ethics; • Respect both the living and the dead while

staying current in necessary lifesaving skills; and

• Ethically perform research to advance the field of emergency care while safeguarding patients.

6

Safety Net Issues

• EDs are overcrowded. • Law mandates that EDs accept, evaluate and

stabilize all patients. • The number of patients seen for issues that

are not true emergency problems has increased.

• Social problems have become medicalized.

7

Safety Net Issues

• Whether to accept all these roles and dilute the mission or

• To ignore all these problems becomes an ethics issue.

• When EDs become overwhelmed, patient mortality is affected.

• Can EDs afford to ignore safety issues?

8

Paternalism

• Paternalism in the ED results in pressure to use time and resources to first assist the most critically ill.

• Medical team actions often result in procedures that are done without true informed consent.

• Paternalism is often part of making decisions about futility.

9

PHDNR and PHAD Orders

• Most EMS systems still require an attempt toward resuscitation.

• Some state laws are changing • States have responded by allowing PHDNR

orders and PHADs. • Despite the benefits, there are still some

challenges with these documents.

10

Assisted Suicides

• The number of failed suicides is expected to increase and,

• The ED rule is to preserve life. • What options should be used in a suicide

attempt? • Should physicians use life-sustaining

treatment to buy time for information gathering?

11

Breaking Bad News

• Communicating bad news in the ED environment can be overwhelming.

• There is a need to respect the recipient’s feelings.

• Training is needed to assist those who must deliver bad news.

12

Surrogate Decision Makers

• Assessing the capacity to consent can be difficult.

• Inebriated and psychiatric patients still retain some levels of capacity.

• The more serious the situation; the more capacity must be present.

• ED personnel must evaluate the patient using several questions.

13

Surrogate Decision Makers

• The situation is more complicated if the patient requires a surrogate to make decisions.

• Advanced directives and surrogate lists assists in the practice of proactive ethics.

14

Provider Security

• Ethics issues arise when the need to be safe conflicts with beneficence.

• Restrictions on entry into the ED have been used to provide safety.

• ED personnel must also protect their own safety.

15

Triage/Disaster Ethics

• EDs and first responders represent the frontline defense against further injury.

• Utilitarianism may be the rule for treating the injured.

• ED staff must be able to quickly switch to disaster mode.

• Bioethics committees need to work on appropriate protocols.

16

Practicing on the Newly Dead

• The public demands skilled practitioners. One way to maintain skills is to practice on the newly dead.

• Recently, consent has become an issue. • The dead have no autonomy claim. • However, the wishes of the person and the

family should be respected.

17

Practicing on the Newly Dead

• Society has an interest in these procedures. • Limits should include respectful treatment of

the body and limiting training to those who must use the procedures.

• Alternates to using fresh cadavers are not as beneficial.

18

Resuscitation Research

• Acute-care research in the ED is justified if the usual requirements for research are modified by

• Using an explicit definition of acute care as distinct from other modes of critical care,

• Eliminating the requirement for informed consent (as usually understood), and

• Requiring stringent IRB oversight regarding the unique ethical problems raised by this.

19

Resuscitation Research

• Frequently, restrictions have been placed on this type of research.

• ASEM says that this research is vital, and that vulnerable populations should not be excluded.

• Informed consent should not be required.

20

Other Areas

• Drug seeking behavior verses true pain management.

• Decision making capacity under severe stress. • Communications through telemedicine can

strain confidentiality. • National ethical standards are needed.

21

In Summary…

22