ethics in emergency medicine2

8/13/2019 Ethics in Emergency Medicine2

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Ethical issues related to emergencymedicine:

1. Informed Consent and Refusal2. Patient Decision Making Capacity3. Treatment of Minors4. Advance Directives5. Limiting Resuscitation6. Futility

7. Confidentiality8. Truth Telling and Communication9. Compassion and Empathy10. Moral Issues in Disaster Medicine


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1. Informed consent & refusal

Define the emergency rule Describe the circumstances underwhich a physician may treat a patientagainst his or her will


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The Emergency Rule

1. Patient unconscious or otherwiseincapable of consenting exception toinformed consent

2. Limited time emergency servicesoperate under the moral imperative ofbeneficence, acting in the best interests ofthe patient.

3. In time of life threatening crisisphysician's duty to do that which theoccasion demands, even without theconsent of the patient.


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Informed refusal

1. Patients with decision making capacity(capacity) have a right n o t to consent tocare.

2. The elements of a valid, informed refusalare the same as consent: capacity &comprehension of information (risks &harm)

3. Refusal of care may conflict withphysicians judgment & recommendation

emphasize the risks & consequences


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4. Both consent and refusal must be madevoluntary , without coercion/duress.

5. Physicians should provide treatment

despite:- a verbal refusal in patients with nocapacity , or- life threat is so acute no time toassess refusal.

6. When patients do not have capacitybenefit must outweigh the potential risk of

harm


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Case 1:25 y.o. with head injury due to trafficaccident, GCS 15, mouth & nosebleeding, mandibular fracture

Doctor suggests head CT-scan,receives informed consent from patient,but disapproved by hospital due to

administrative matter (who will pay?)


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2. Patient Decision MakingCapacity

Define decision making capacityContrast medical interpretations ofdecision making capacity with thelegal definition of competence.List the ways decisions can be madewhen a patient lacks decision-making

capacity


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The Medical Concept of Decision MakingCapacity

All adult patients unless there is evidenceobtained by history, behavior, or physicalexamination

The determination of decision making capacityrequires that:

1. The patient appreciates he/she has the power tomake decisions on his/her behalf

2. The patient understands - the medical situation & prognosis ,

- the nature of the recommended evaluation or care,- the alternatives, - the risks & benefits of each, and- the likely consequences

3. The patient's decision is stable over time, and isconsistent with his or her life values or oals.


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Level of capacity

The degree/level of decision-makingcapacity varies with the degree &probability of risk, benefit, & patient's

decision to consent/refuse.

The greater the risk the more exactingthe standard of capacityA patient might need a low level ofcapacity to c o n s e n t to a procedure withsubstantial benefits and minimal risks, but

a high level of capacity to r e fu s e the same


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The Concept of Legal Competence?

Each state may have slightly differentcriteria for the determination of

competenceHow about Indonesia??


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Case 2:

60 y.o. referred from private hospital with(suspect of) CRF (7 days of hospitalization,a s k e s k i n )

Arrived in E.R. unconscious (somnolen, GCS12), suspect of metabolic disorderLatest lab results reveal normal, doctors

advise head CT-scan to find etiology &establish diagnosisWife disagrees (wishes for homecare) butchildren agrees to go on


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3. Limiting Resuscitation

Define "Do Not Resuscitate Order" (DNRorder).

Explain conditions which must be present towithhold resuscitation Explain the role of family and significantothers in decisions about resuscitation.


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Withhold & withdraw?

Withholding & withdrawing: no moraldifference

Indeed a difference, but not a moral one initselfThere can be a moral difference in somesituationsCreates potential difficulty for families, aswell as for physicians


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It is legally and ethically acceptable towithhold resuscitation attempts onpatients who have expressed clear wishes(Indonesia?)

Challenge communication means ofcommunication must be legally, ethically,and medically sound (ex: form with patient

& physician signature, patient arm-band,etc.)

Emergency setting presents difficultiespatient's wishes, medical condition, andprognosis are usually unknown.


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If there is doubt resuscitative effortsshould be initiated.

The decision to resuscitate must be animmediate yes or no decision.

"Slow codes," suboptimal effort, ordelayed intervention are nevermedically or ethically acceptable.


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Case 3:30 y.o. in coma due to traffic accident,GCS 4Develops respiratory failure doctorsuggest patient put on NRM / ventilatorAfter 3 hours parents decide to stoplife support & bring home their child on

whatever condition


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ReferenceBlank R., Merrick J. (ed). End of Life DecisionMaking. A Cross-National Study. Cambridge:MIT Press, 2005

Peterson L. Workshop and Panel Discussionon End of Life: Developing palliative careunit & strengthening hospital ethicscommittee. Yogyakarta, 15-17 January 2008

SAEM Ethics Committee Ethics Curriculumfor Emergency Medicine Residencies,1994

ethics in emergency medicine2

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