If an investigation reveals that a vulnerable person isn’t getting enough care or assistance at home, they can help to ensure that the neglected person gets the help that they need, which could include home nurse care, education for the care provider, or placement in a different home. Web. When a competent adult patient expresses their personal wishes for their healthcare, that information must be respected above all other directives, even if thirty family members disagree vehemently. These programs may provide valuable information to assess the history and use of controlled substances and contribute to clinical decisionmaking in the emergency department (ED). Ethical concerns also arise because patients use the ED for chronic care management. However, withholding heroic measures in respect for one’s wishes are a very different thing, and they are not active allowance of death, nor do such actions cause death. Patient advocacy as a tool to lessen these ethical issues is further discussed. Although professional responsibilities have been a concern of physicians since antiquity, recent years have seen dramatic growth of both professional and societal attention to moral issues … Accessibility Statement, Privacy Emergency Medicine is a specialty that you may not think involves a lot of ethical dilemmas. Preparing for or responding to emerging threats such as bioterrorism and SARS only increases the strain on the system. A. That may mean holding a psychotic or homicidal patient in the hospital against their will until you have input from social work and psychiatry that reassures you that the patient is no longer dangerous. My father must have been confused because he’s so sick.” You feel that his father was not confused and expressed his wishes knowingly and genuinely, and his son is furious and accuses you of trying to kill his father by withholding care that he would want and threatens to sue you and the hospital for murder. The patient is now barely conscious and unaware of his surroundings. A study by Anderson-Shaw et al has suggested that patients hospitalized through ED often present with ethical dilemmas significantly impacting their inpatient care and overall health outcomes [ 13 ]. Appreciate the challenges of following a patient’s direction when those decisions are in conflict with their family’s wishes In many medical schools there is little ethics training during the clinical years. In the emergency department, adolescents can therefore be treated for issues relating to reproductive care without parental consent. You called the hospital’s social worker to come and see the patient in the ED, and you ask the patient for permission to call her mother and father to explain the situation and pick their son up at the neighbors’ home. If you don’t know what to tell them, then be open about that as well and then suggest what you might do in their situation, always being gracious to express that you have deep empathy for the difficult decisions that they are making and that you deeply respect their decision-making process. “Ethical Challenges in Emergency Medical Services.” Ed. Author information: (1)Center for the Study of Bioethics, Medical College of Wisconsin, Milwaukee. The family has a long and heated discussion and two family members are angry, the rest of the family is compassionately understanding and advocates for their father’s expressed wishes to remain DNR/DNI. Frequently, families ask you what you think they should do. Annals of Emergency Medicine. Career Development and Mentorship Committee, Communications and Social Media Committee, Effective Consultation in Emergency Medicine Video, Residency Match in the Era of COVID: Advice for Medical Educators in Emergency Medicine, SAEMF/CDEM Innovations in Undergraduate Emergency Medicine Education Grant, The Power of Mentorship: Pearls and Pitfalls in Medical Education Research, Clerkship Coordinator’s Handbook Clerkship Coordinator’s Handbook, Virtual Rotation and Educational Resources, Diversity, Equity, and Inclusion (DEI) Library, Identify the four major ethical principles of the doctor-patient relationship, Understand the obligations of a mandated reporter, List the agencies that investigate possible harm or neglect of those who cannot care for themselves, Appreciate the challenges of following a patient’s direction when those decisions are in conflict with their family’s wishes, Beneficence describes our overall goal to help our patients, Nonmaleficence is the principle that we should not harm our patients, Autonomy is our duty to respect our patient’s wishes, When we treat our patients rightfully despite their lifestyle or creed, we are upholding medical justice, If you openly consider these principles when you find yourself in an ethics dilemma, they can help you to make challenging decisions. About Countless emergency departments are literally on life support as they try to cope with capacity issues and workforce shortages. Physicians are mandated reporters, which means that we are legally mandated to report suspected abuse or neglect. He begins to grow confused as his blood pressure gradually drops, and you call his family to be at his bedside because you suspect that he is close to death. Emerg Med Clin North Am. As the premier organization for high-quality research and educational innovation in emergency care, the Society for Academic Emergency Medicine (SAEM) creates and promotes scientific discovery, advancement of education, and the highest professional and ethical standards for clinicians, educators, and researchers. Do no harm. Ethics in Emergency Medicine: An Overview. Family members are frequently wonderful advocates for one another, but sometimes they have an incomplete understanding of their own parents’ wishes or children’s wishes, and that incomplete understanding can lead to huge conflict in the ED in emotionally charged situations. That means that Emergency Physicians form many new Physician-Patient relationships each day with each new patient. Emergency Physicians must perform an assessment and stabilize a patient prior to transferring them or discharging them. That means we are mandated to report situations that are placing others outside of our care at risk to the correct authorities. [Ann Emerg Med. His son arrives in the ED and becomes very upset when he sees his father dying. If a patient admits they plan to harm another person, you are obligated to warn that person. Adult protective services specializes in investigating cases of abuse or neglect of the elderly or of adults who cannot fully care for themselves, If you report suspected abuse or neglect in good faith, you will not get into trouble for reporting your suspicions or fears, A competent adult patient has the right to accept or refuse any offered medical care, and the patient’s wishes take precedence over the wishes of their family members, If a patient expressed healthcare wishes while competent and then becomes ill and cannot make their own decisions, their most recently known wishes must be honored, While you must act as an advocate for your patient above all others, if you express empathy towards their family in times of conflict, your affect can greatly decompress chaos and tension, If you need help with an angry family in the ED, ask for help. The issues of pain management in the presence of addiction needed to be discussed in relation to the ethical principles of autonomy, nonmalficence, beneficence, and informed consent. He never appears to be in pain or wakes up after his ED assessment. You aren’t a murderer if you fail to prolong someone’s life in accordance with their wishes to limit their perceived suffering. “ACEP Code of Ethics for Emergency Physicians.” A Compendium of ACEP Policy Statements on Ethical Issues Revised 2002, 2003, 2004, 2005, 2006, 2007, 2008, 2009, 2011, 2012, 2013, 2014: 1-12. Your job is to merely report your concern so that it can be investigated. | Web. You carefully repair the patient’s arm laceration and when she appears sober, you counsel her in a heartfelt way about the importance of sobriety while caring for a child and offer alcohol abuse counseling. He returned to the Emergency Department in an ambulance an hour later because his chest pain returned when he got home, and this time he agrees to undergo catheterization and thanks you for being patient and compassionate with him during his first visit to the ED, admitting he wouldn’t have returned to the hospital at all if he hadn’t been so impressed by your respect of his right to autonomy. They merely avoid certain potentially challenging situations that oftentimes prolong death or delay death or sometimes prevent it. Emergency physicians have unique ethical issues in their practice of medicine. The current state of scientific knowledge on using the emergency department (ED) for chronic care management indicates that using the ED for chronic care management creates health disparities and burdens healthcare systems. He is initially alert in the ED so you ask him about his wishes if his condition were to worsen. Web. You’re responsible for failure to report legally and can lose your license to practice medicine, and you’re also ethically responsible for failing to protect those who need your help. Clinical & Practice Management. Schmidt, Terri, Beckman Girod, Stephanie Hollingsworth, Jason Hughes, Jayne MacLaughlin, Catherine Marco, Brian McBeth, Katie McClure, Tammie Quest, Raquel Shears, and Drew Watters. What do we do when our respect for patient autonomy and beneficence seem to work against one another? Your third patient of the afternoon is Mr. L. G., an elderly man with metastatic cancer and pneumonia with sepsis. Vol. When children and teens are seen in an emergency department (ED) without their parents or legal guardians, ED physicians wrestle with a host of legal and ethical concerns. In situations of family conflict, it is important to remain emotionally gracious and open with families and to attempt to diffuse the emotionally charged nature surrounding the conflict. You speak more extensively with the patient and discover that she is not usually the babysitter for her brother. 1 Dec. 2015. He is sober, does not wish to harm himself, and expresses that he wants to go home to mull over his treatment options. In cases where a patient is an imminent danger to themselves or others, you are obligated to protect the patient and others. HIV and AIDS. As the Affordable Care Act is implemented and more people obtain insurance coverage, it is likely there will be even higher ED volumes. You ensure that the toddler is not home alone by confirming that he is with their neighbors. (Galen Press, 1995)) is relatively out of date.It is a crucial resource for all emergency professionals and anyone with an interest in emergency medicine ethics. These programs may provide valuable information to assess the history and use of controlled substances and contribute to clinical decisionmaking in the emergency department (ED). Prescription drug monitoring programs are statewide databases available to clinicians to track prescriptions of controlled medications. 2, Patient advocacy: A tool for resolving ethical issues for patients that use the emergency department for chronic care management, LaWanda Baskin, The University of Southern MississippiFollow. Ethical issues in the emergency department: consent for procedure training on newly deceased patients. She explains that she was heating up the lasagna to feed her four-year-old brother breakfast as she was babysitting him. If someone’s father or mother or sister or brother dies, that is a traumatic and difficult event for the family member. Second, the number of patients whose ED charges would be reimbursed increased greatly after 1965 when Medicar… The physician-patient relationship is a special and privileged relationship based on four major ethical principles: We have the duty to serve our patients’ best interests by treating or preventing disease or injury and by informing patients about their conditions. “Guide to Teaching Ethics in Emergency Medicine Residency Programs.” SAEM Ethics Committee (2005): 1-95. OJHE Child protective services (CPS) specializes in investigating and ensuring safe care for children. She is only visiting briefly and is the babysitter for a single morning while her mother and father are at a medical appointment. However, ethics is actually really central to our practice. The medical ethicist supports your need to uphold the patient’s wishes and speaks with the patient’s son and other family members who are now arriving in the ED and the chaplain speaks with the family graciously and extensively. If you report a concern, you don’t need to be correct. You explain the situation to the medial ethicist and the patient representative, and you stand your ground because you feel that you must advocate for the patient, especially now that your patient can no longer advocate for himself. It means that if a patient has an incurable or dangerously virulent disease that they could spread to others and are keeping that disease a secret, you are obligated to warn those at risk. Ethical problems are often exacerbated by time constraints, lack of detailed information, and a high incidence of impaired cognitive abilities in the patients. My Account He understands that you think his heart could be permanently damaged beyond repair, leading to heart failure, arrhythmias or death within the next few days. She gives you permission. Which principles of ethical patient care were enacted from the moment J. M. arrived? Two factors significantly contributed to patients’ use of hospital emergency departments (EDs) for medical care and motivated the federal government to regulate that care. Prehospital and Disaster Medicine (1993): 1-8. He clearly affirms to you that he does not wish to be intubated or to receive CPR because he has been fighting cancer for a long time and doesn’t feel that heroic measures would be in his best interests. Your second patient of the day is Ms. R. S., a 21-year-old female with an arm laceration. Whilst ethical principles are designed to be used in any setting, this article develops their application in clinical practice in the Emergency Department. It is important for the emergency department physician to understand the rules surrounding the care of pediatric patients to avoid compromising their privacy and ultimately their well-being and medical care. Patients have the right to privacy, and you must strive to act in a beneficent manner to protect your patient’s basic rights, including the rights to health, safety, and privacy. It sometimes involves quick scenarios, unexpected patients, and a special sense of urgency to most of the cases. You think that the child in this case may not have been supervised adequately this morning, but they’re probably well supervised at other times. You return to the patient’s bedside, where he remains stable appearing and says he feels much better. | The benefits of reflective essay writing in ethics … However, it is most important to respect the wishes of the person who is living or dying in the process, and sometimes you need to aggressively advocate for your patient. The ethics of that decision are hotly debated. Different religious groups and national backgrounds approach decisions surrounding death in different ways. We must be fair and impartial to patients’ gender, race, age, ability to pay and demeanor when we treat them, regardless of one’s own beliefs. Emergency department crowding and the resultant long wait times are a predictable and common condition across a wide range of hospital ty… Adams, James. Herbert Garrison and Normal Dinerman. 59(3): 177-187. The fact that the emergency department affords every patient the required-by-law medical screening exam—and usually a diagnosis and treatment as well—has led to nonurgent ED visits, which are blamed for cost overruns and for clogging the system with patients … | Your first patient of the day is Mr. J. M., a very nice 58 year old man who was visiting his brother here in town when he became ashen, sweaty and admitted to his family that he was having chest pains. He states “I just don’t feel like I should stay in the hospital if I’m not having pain. This is the third paper on research in accident and emergency medicine. You aren’t a judge. Some of our patients or family members of our patients cannot feed themselves, clean themselves or keep themselves safe without assistance. Social workers and psychiatry teams are very good at assisting you in this process, but the responsibility to protect the patient and anyone threatened falls upon you. We can offer beneficent care but a patient’s autonomy directs whether or not they accept that care. Originally approved September 2005 titled "Ethical Issues in Emergency Department Care at the End of Life" The American College of Emergency Physicians believes that: Emergency physicians play an important role in providing care at the end of life (EOL). After calling the child’s parents to explain that he is being cared for by his neighbors, you contact child protective services and they open an investigation and reassure you that they will visit the home today to speak with the child’s parents and assess the home for safety. Ethical Dilemmas in Emergency Medicine provides invaluable information, perspectives, and solutions to common ethical dilemmas in emergency medicine. “This outstanding work immediately becomes the standard textbook for ethics in emergency medicine, as the best competing text (Ethics in Emergency Medicine, 2nd edition, Iserson et al. To allow someone to die without performing CPR or intubating them if they do not wish for those interventions is to be ultimately non-maleficent. Other Nursing Commons. Research done on emergency department nurses shows that a large majority of them experience multiple "critical incidents." I will come back if anything happens. Two categories emerged: one in ‘ethical issues’ and one in ‘emotions and feelings in caring’. Key implications from this research are the need for patient advocacy to improve health literacy, self-care behaviors, and social support among patients with chronic conditions. Citation: McClelland, M., (March 6, 2015) "Ethics: Harm in the Emergency Department- Ethical Drivers for Change" OJIN: The Online Journal of Issues in … II. More importantly, you did what you could to make sure that a vulnerable person is getting the help that they need. Adult and emancipated patients with decision-making capacity have the right to accept or decline offered health care, and physicians have a duty to respect the decisions of their patients. If a person is of sound mind and wishes to accept or decline offered care and they are informed about what that decision may entail, that decision is the bottom line. You explain to him that he is having a heart attack and the treatment is cardiac catheterization to re-establish blood flow to his heart in order to prevent more damage to his heart and possibly save some injured heart muscle. When a patient comes to the Emergency Department for help, they have a right to emergency stabilization whether or not they have the ability to pay and regardless of their age, gender, race, or beliefs. ten minutes prior to Mr. J. M. did. He also declines placement of a central line for aggressive care of his sepsis. The lab calls you with a critical result: his troponin is 130 (negative: under 0.01). This right has been written into law, under the Emergency Medical Treatment and Active Labor Act (EMTALA). Use the tools at your disposal, because taking action to advocate for a patient is the greatest way that you can show respect for your patient, regardless of what your thoughts or wishes might be for them, and you must do so while attempting to provide the most positive and compassionate experience possible for their family, who is also suffering in a different way. : Emergency Medicine” series, Legal and Ethical Issues in Emergency Medicine uses a case-based approach to cover common and important topics in the legal and ethical dilemmas that surface in the practice of emergency medicine. We might not realise it, but there are ethical implications for every single decision we make. Des Plaines, IL 60018 Part of the “What Do I Do Now? When patients arrive in the ED, the triage nurse has little time to gather detailed information. In some states and in some other countries, actively prescribing a quantity of medicine to hasten or cause death at the direction of a competent and well-minded patient is legal. The more backup you have, the better. She explains “I lost my balance in the kitchen while I was heating up lasagna” at 6am, and appears to be intoxicated and smells strongly of alcohol. Home you may Download the file to your hard drive. Physicians are mandated reporters. interpretation and use of POLST in the emergency department do exist. Which is a greater responsibility: the responsibility of respecting your patient’s privacy or the responsibility to protect others? Schoolteachers, priests, nurses, and many others are also mandated reporters. 1 Dec. 2015. His son demands that the patient should have a central line placed and that he should be intubated, and when you compassionately explain that his father had expressed that he did not want a central line or to be intubated, his son argues “My father would never want that – our beliefs are that we should do everything to stay alive. It discusses the ethical issues in emergency medicine with particular regard to informed consent and the privacy of subjects and patients. Since 1999, visits have risen from 103 million (378 visits/1000 persons) to almost 130 million (428 visits/1000 persons) in 2010 (Centers for Disease Control, 2014). Medicine and Health Commons, If you know what the right thing to do happens to be, stand your ground. Social workers are usually available to help you to make a report, and CPS and APS hotlines and websites also help to walk you through the steps of mandated reporting. The authors summarize key elements contained in the Institute of Medicine work on crisis standards of care. The treatment of individuals infected with HIV in the emergency department presents difficult and unique medical, social, legal, and ethical issues. This respects their personal autonomy. Ethical issues are hardly considered in emergency department setting. I feel fine now. If you show empathy and concern towards your patient they’ll frequently give permission to call the parents and discuss the whole situation, which may help the parents to make responsible future babysitting decisions. That takes practice and experience, and diffusing a difficult and conflicting situation is not always possible. The Emergency Department is a specific setting where the challenges of delivering ethical care are especially pronounced related to time pressures, urgency and acuity. Emergency department (ED) utilization continues to outpace population growth. Working in the emergency department gives rise to unique ethical considerations. To view the content in your browser, please download Adobe Reader or, alternately, Derse AR(1). Sometimes, another personality joining the fray will help to diffuse the conflict better than you alone because if you are the first physician to put up resistance to a family member’s wishes, they may feel embittered towards you even if you are extraordinarily diplomatic. > 2014;64:140-144.] He thoughtfully responds “I would prefer not to stay in the hospital – I feel okay now and I don’t like hospitals. Ethical Foundations of Emergency Medicine. > Ethical concerns also arise … Adult protective services (APS) does the same for elderly patients and other adults who cannot care for themselves fully, such as disabled adults or mentally handicapped adults. The widespread availability of the programs raises important ethical issues about beneficence, nonmaleficence, respect for persons, justice, confidentiality, veracity, and physician autonomy. You openly invite him to return to the ED any time that he wants and if he changes his mind, you alert triage to his situation in case he returns so that they can rapidly triage him and he can be immediately seen if he returns, and you discharge him from the ED making an extensive note that he declined therapy and left against medical advice. Likewise, there exist unique patterns of ethical dilemmas that are regularly encountered in the emergency department. Ethical Issues in the Response to Ebola Virus Disease in United States Emergency Departments: A Position Paper of the American College of Emergency Physicians, the Emergency Nurses Association, and the Society for Academic Emergency Medicine Emergency Department Principles. If you don’t know what the right decision is, get help from an ethics consultation or patient representative, an emergency medicine administrator, the chaplain, or anyone at your disposal. NOTE: The latest versions of Adobe Reader do not support viewing PDF files within Firefox on Mac OS and if you are using a modern (Intel) Mac, there is no official plugin for viewing PDF files within the browser window. Author: Erin E. Dancour, MD, MS, FACEP, Columbia University, Editor: Matthew Tews, DO, MS, Medical College of Wisconsin. He is admitted to the ICU on peripheral vasopressors and dies the next day from sepsis. You discharge your patient from the emergency department. The patient's behavior compelled our ED personnel to examine the ethical issues surrounding this case. A podcast for this article is available at www.annemergmed.com. > 1995 Feb;13(1):213-23. Legal and ethical issues in the emergency department. Copyright, University of Southern Mississippi Libraries. This is the reason patients trust us – they have faith in us that we will not harm them. 1111 East Touhy Ave, Suite 540 When Mr. J. M. presented to the Emergency Department, he was immediately seen by the medical team because his complaint of chest pain was considered to be of greater potential danger to his health than the complaint of another patient who came to the E.D. She admits that she was the only person at home with him this morning, and she admits “last night I drank a lot because I was out with friends”. The current state of scientific knowledge on using the emergency department (ED) for chronic care management indicates that using the ED for chronic care management creates health disparities and burdens healthcare systems. Some families are all on the same page, some families are wonderful at designating a single decision maker to express a dying or incapacitated family member’s wishes and to make decisions on their behalf, and some families are thrown into chaos with a confusing mix of opinions on the table in life-or-death situations. However, if you don’t report something that concerns you and sends up red flags in your mind and a child or elderly person is injured or abused, you are responsible for that injury or abuse because you didn’t report your fears. A repeat EKG shows ST elevations in the anterior leads V1 and V2. In this article, we will discuss the history, ethical considerations, legal issues, and emerging trends in the use of POLST documents as they apply to emergency medicine. His brother insisted on bringing him to the Emergency Department, where his EKG shows ST depressions in V4, V5 and V6. To help pediatricians working in the emergency medical environment, the Academy … After a heartfelt conversation with Mr. J. M., he expresses that he understands your concerns and fears. Even if a patient does not agree with our treatment recommendations, we can provide them with compassionate counseling and should assist them and stabilize them as completely as we are able. The ethical right for individuals to have access to health care already has a form of legal binding within the United States as seen in the Emergency … Sometimes, a patient’s right to privacy conflicts with the interests of someone who you aren’t treating in the ED. Bioethics and Medical Ethics Commons, Whenever possible, you can reach out to guardians without violating your patient’s confidentiality to let them know that you’re treating the child’s caregiver and need help with arranging supervision for the child in the meantime. As an emergency physician, you need to be able to identify the situation at hand and juggle the various personalities involved in an effort to make everyone felt like they have been heard while also helping the family come to a sound and clear decision. Sometimes families prefer to have huge amounts of information and then they weigh this information and make elaborate decisions, sometimes with the input of their religious leaders. You will encounter families that are very stoic and families that are very outwardly emotional. You summon assistance by calling for a patient representative to join you and you page the medical ethicist so that you can have support at your side, as the patient’s son is already furious with you and it’s possible that he could have an improved and more productive relationship with other personalities and communication styles from other medical care providers. | Child protective services specializes in investigating cases of child abuse or neglect. The Clerkship Directors in Emergency Medicine (CDEM) is an Academy of SAEM. We also must protect our patients’ right to confidentiality. If you feel as though you are getting into trouble because of conflict in the ED, summon help.