NATIONAL HARBOR, Maryland — Between suicidal patients, unclear Do Not Resuscitate orders and patients who may lack decision making capacity, doing what’s right for the patient may not always be straightforward.
Keith Wesley, M.D., medical director, HealthEast Medical Transportation; and Jared Ross, D.O., firefighter/EMT-T, EMS fellow at Washington University in St. Louis, waded through these murky waters with attendees at EMS Today at a session titled, “Difficult Ethical Challenges in Prehospital Medicine: A Case Study Review.”
Top quotes on ethical considerations in EMS
Here are quotes from Keith Wesley on medical ethics that stood out from this presentation.
“When I look at our profession, it’s this – these repeated exposures to these unresolved ethical challenges – which leave scars on our psyche.”
“Inaction is action.”
“In medicine, you can’t make your decision based on whether or not someone’s going to arrest you or sue you.”
Top takeaways on medical ethics
At the end of the day, taking away the questions; “Did I do the right thing?” “Was there another option?” “Was there more I could do?” will help EMS providers cope with the stress of the job, and contribute to their longevity in EMS.
Here are the strategies Wesley and Ross provided for tackling ethical challenges.
1. Understand what medical ethics is not
Wesley provided the definition of medical ethics – “principles of proper professional conduct concerning the rights and duties of the provider to their patient” – but then noted it’s easier to understand what ethics is not.
Ethics is not:
- Feelings. “Feelings can change,” Wesley noted. Making the wrong choice multiple times can give a false confidence in your feelings. Consider: “Do trust your gut,” Wesley stressed. If you have a pit in your stomach, if anything that will at least identify an ethical challenge.
- Religion. We each come on to the scene with our own religious mores or beliefs. Consider: These are our own, not the patient’s morals or conceptualization of right and wrong, heaven and Hell.
- Law. Providers often ask, “is that legal?” “Yes, liability is a concern, but ethical decisions sometimes need to be made against the law,” Wesley explained. “A good system of law does incorporate many ethical standards, but law can deviate from what is ethical.” Consider: Things can be legal, yet unethical.
- Cultural norms. “Cultural norms and religious mores often overlap,” Wesley noted. “We can easily blunder in cultural norms.” He recalled his early days in healthcare where he used to pay young children on the head before learning within the large Laotion population in his community, the gesture from a medicine man was viewed as cursing the child to death. Consider: Does your service represent or identify with the cultures of the citizens you serve?
- Science. Science is what’s possible; ethics is concerned with what’s appropriate. Consider: It’s scientifically possible to clone a human being, or to conceive a child via in vitro fertilization to donate an organ to a sibling. But is it ethical?
2. Learn to weigh and balance the 4 pillars of ethics
Wesley laid out the four principals of ethics for attendees:
- Autonomy. Competent persons have the right to make their decisions free from interference; a right to say what’s done to them and this extends to their health information.
- Beneficence. Show kindness, charity and mercy. Medical professionals have a moral responsibility to help and do good.
- Non-maleficence: Do no harm – Primum non nocere – understanding that a failure to act also counts if it causes harm. Remember that “good” should be defined by the patient. “‘The doctor knows best’ does not apply,” Wesley stressed.
- Justice. Patients have a right to be treated fairly despite their age, gender, race and social status.
Remember to each of the pillars are equal, Wesley cautioned. “Historically, we have placed autonomy at the height but forget the other three.” Ethical challenges will require placing one pillar over another when they conflict. For example, placing a patient under an involuntary hold or restraint violates their autonomy, but allow you to practice beneficence when the patient is not of sound mind to choose their own good.
“Often, an ethical challenge will require choosing the least bad solution,” Wesley said.
3. Use an algorithm to make ethical decisions
When faced with a challenge, ask yourself if you’ve faced a similar situation in the past. If you feel confident in the way you resolved this situation before, take the same approach.
If you need a new approach, or are faced with a new scenario, there is an algorithm to follow when faced with an ethical challenge, Wesley revealed. Consider these three justifications for your choice:
- Partial. If you were the patient, would you be OK with your provider acting in this way?
- Universal. Would you be comfortable if all providers with your background took this approach across the board, making it the rule?
- Justified. Would you be willing to stand before your peers, the public and a prosecutor to justify your actions?
If you’re not sure what to do, consider, is there an option which will buy you time? Sometimes, the answer is to keep the patient alive until hospital physicians can make the call.
We in EMS are certainly trained and smart enough to make these decisions, but it should not be our burden, Wesley said. We do no enjoy the luxury of full medical records, quiet rooms and chaplains, and auxiliary staff.
3. Implement ethics policies, training
While there may be no clear-cut response for ethical challenges, there are common themes EMS agencies and providers are sure to encounter. Wesley gave the example of a patient rapidly declining during a long transport to a nursing home for hospice care. The patient’s family was following behind, hoping to say goodbye, and the facility would not accept deceased patients. “Our failure was in no having a plan in place,” Wesley noted. “If the patient looks near death, have a plan.”
Your agency should have policies in place for situations with an ethical component, including:
- Confidentiality
- Palliative care
- Death notification
- Vulnerable adults
- Mental capacity
- Informed consent
- Termination of resuscitation
- Mental health
Once you appreciate and identify the ethical challenges your providers will face, and the role each pillar plays, the next step is implementing a framework to train on ethical considerations in your service, Wesley added.
He includes an ethical challenge in each training activity for EMTs and paramedics, from a religious exception in a pediatric advanced life support scenario, to a DNR in cardiac arrest training. “That’s real life,” he explained.
Ethical challenge scenarios
Emergency services personnel make difficult decisions every day. From the extreme – like the physician who terminated patients during Hurricane Katrina when there was no rescue in sight, to the everyday triage decisions made in multiple casualty incidents, the decisions will weigh less heavily with proper education, policy and training.
Wesley and Ross ended the session by opening up the following ethical challenges for discussion and debate. Consider these scenarios:
- You respond to a 47-year-old patient who is emaciated, near death and in respiratory distress. The sister, who has been caring for the patient, tells you a hospice nurse is coming in the morning to sign the DNR. The father, who has just arrived, doesn’t know what to do.
- You respond to a residence where a 57-year-old patient Is unresponsive with agonal respirations. Empty bottles of OxyContin and Zanax are visible. You lose a pulse and begin CPR. The wife tells you the patient has ALS and presents a valid DNR.
- A 75-year-old patient is being discharged home, an hour away. He has labored breathing, with O2 sats in the 80s despite 100 percent oxygen. He has a valid DNR, but the daughter wants you to make him comfortable.
- You respond to a two-vehicle collision and find the passengers of a van, a family of five, all dead. The driver of the semi-truck admits to drinking and drug use. When police arrive on scene, they ask you if the driver has been drinking.
What would you do? Add your comments below.
Additional resources on medical ethics
Learn more about medical ethics challenges and training with these resources from EMS1:
- Research Analysis: Conclusions about ‘moral hazard’ of naloxone not supported by methodology
- Inside EMS Podcast: The difference between in-hospital and out-of-hospital DNRs
- Ethics in EMS: 10 things you need to know to save lives
- Naloxone and the EMS conundrum: Public policy considerations
- EMS policy change and QI: Plan, Do, Study, Act
- Unconscious man with ‘Do Not Resuscitate’ tattoo sparks dilemma
- DNR tattoos: Are they legal and is EMS bound to comply?
- Death in public places, is your organization prepared? We were not
