Ethics for EMS Providers

ETHICS IN ADVANCEDETHICS IN ADVANCEDPREHOSPITAL CAREPREHOSPITAL CARE

TopicsTopics

EthicsEthics MoralsMorals Law Law Advanced DirectivesAdvanced Directives

IntroductionIntroduction

In one survey, almost 15% of ALS calls in an In one survey, almost 15% of ALS calls in an urban system generated ethical conflict.urban system generated ethical conflict.

In another survey, EMS providersIn another survey, EMS providers reported frequent ethical problemsreported frequent ethical problems related to patient refusals, hospitalrelated to patient refusals, hospital destinations, and advance directives.destinations, and advance directives.

IntroductionIntroduction

Other aspects include patientOther aspects include patient confidentiality, consent, the confidentiality, consent, the obligation to provide care, andobligation to provide care, and research.research.

MORALSMORALSMORALSMORALS

Social, religious, or personal Social, religious, or personal standards of right and wrong standards of right and wrong

ETHICSETHICSETHICSETHICS

The rules or standards that govern the The rules or standards that govern the conduct of members of a particular conduct of members of a particular

group or professiongroup or profession

Ethics Ethics VS. VS. MoralsMorals

Ethics and morals are Ethics and morals are closely related concepts closely related concepts but distinctly separate.but distinctly separate.

Ethics are the rules or Ethics are the rules or standards that govern standards that govern the conduct of members the conduct of members of a particular group or of a particular group or profession.profession.

Morals are the social, Morals are the social, religious, orreligious, or

personal standards personal standards of right andof right and

wrongwrong

Relationship of Ethical and Legal Relationship of Ethical and Legal Issues with MedicineIssues with Medicine

Approaches to Making Ethical DecisionsApproaches to Making Ethical Decisions

Ethical relativism suggests thatEthical relativism suggests that each person must decide how to each person must decide how to behavebehave

and whatever decision that person and whatever decision that person

makes is okay.makes is okay. Some say, “Just do what isSome say, “Just do what is

right.” right.”

CHOICES CHOICES & &

CONSEQUENCESCONSEQUENCES

Approaches to Making Ethical DecisionsApproaches to Making Ethical Decisions

The deontological methodThe deontological methodsuggests that people shouldsuggests that people shouldsimply follow their duties.simply follow their duties.

Followers of consequentialismFollowers of consequentialismbelieve that actions can only bebelieve that actions can only bejudged after we know thejudged after we know theconsequences.consequences.

Code of EthicsCode of Ethics

Many organizations have Many organizations have developeddevelopeda code of ethics over the a code of ethics over the years foryears fortheir members.their members.

Most codes of ethics Most codes of ethics address broadaddress broadhumanitarian concerns humanitarian concerns andandprofessional etiquette.professional etiquette.

Very few provide solid Very few provide solid guidance onguidance onthe kind of ethical the kind of ethical problemsproblemscommonly faced by commonly faced by EMS Providers.EMS Providers.

To gain and maintain the To gain and maintain the respect of their colleagues and their respect of their colleagues and their

patients, it is vital that individual patients, it is vital that individual paramedics exemplify the paramedics exemplify the principles and values of principles and values of

their profession.their profession.

The single most important question The single most important question a paramedic has to answer when a paramedic has to answer when

faced with an ethical challenge is:faced with an ethical challenge is:

WHAT IS IN THE PATIENT’S BEST INTEREST?

4 Principles to Resolve Ethical 4 Principles to Resolve Ethical ProblemsProblems

BeneficenceBeneficence is the principle of doing is the principle of doing good for the patient.good for the patient.

Non-malfeasanceNon-malfeasance is the obligation notis the obligation not to harm the patient.to harm the patient.

AutonomyAutonomy is a competent adultis a competent adult patient’s right to determine whatpatient’s right to determine what happens to his or her own body.happens to his or her own body.

Justice Justice refers to the obligation torefers to the obligation to treat all patients fairly.treat all patients fairly.

BeneficenceBeneficence is the principle of doing is the principle of doing good for the patient.good for the patient.

Non-malfeasanceNon-malfeasance is the obligation notis the obligation not to harm the patient.to harm the patient.

AutonomyAutonomy is a competent adultis a competent adult patient’s right to determine whatpatient’s right to determine what happens to his or her own body.happens to his or her own body.

Justice Justice refers to the obligation torefers to the obligation to treat all patients fairly.treat all patients fairly.

An approac

hto

ethical decision-making.

Quick Ways to Test EthicsQuick Ways to Test Ethics

Impartiality test-Impartiality test-----asks whether you would be asks whether you would be willing to undergo this procedure or action if you were willing to undergo this procedure or action if you were in the patient’s place.in the patient’s place.

Universalizability test-Universalizability test---asks whether you would --asks whether you would want this action performed in all relevantly similar want this action performed in all relevantly similar circumstances.circumstances.

Interpersonal justifiability test-Interpersonal justifiability test---asks whether --asks whether you can defend or justify your actions to others.you can defend or justify your actions to others.

Ethical Issues in Contemporary Paramedic Ethical Issues in Contemporary Paramedic PracticePractice

Resuscitation AttemptsResuscitation Attempts ConfidentialityConfidentiality ConsentConsent Allocation of ResourcesAllocation of Resources Obligation to Provide CareObligation to Provide Care TeachingTeaching Professional RelationsProfessional Relations ResearchResearch

Resuscitation AttemptsResuscitation Attempts

Learn the local laws regardingLearn the local laws regarding ddo o nnot ot rresuscitate (DNR) orders.esuscitate (DNR) orders.

““When in doubt, resuscitate.”When in doubt, resuscitate.”

ConfidentialityConfidentiality

Your obligation to every patient isYour obligation to every patient is to maintain as confidential theto maintain as confidential the information you obtained as a resultinformation you obtained as a result of your participation in the medicalof your participation in the medical situation.situation.

Reporting certain information suchReporting certain information such as child neglect or elder abuse areas child neglect or elder abuse are exceptions.exceptions.

ConsentConsent

Patients of legal age have thePatients of legal age have the right to decide what healthcareright to decide what healthcare

they will receive.they will receive.

Implied consent may apply inImplied consent may apply in cases where the patient iscases where the patient is incapacitated or unable toincapacitated or unable to

communicate.communicate.

ConsentConsentConsentConsent

Patients are generally able toPatients are generally able to consent or refuse care if they are consent or refuse care if they are alert and oriented, aware of theiralert and oriented, aware of their surroundings, and making soundsurroundings, and making sound judgments.judgments.

When leaving the patient, he or she When leaving the patient, he or she must must understand the issues at hand understand the issues at hand and be able and be able to make an informed to make an informed decision.decision.

Allocation of ResourcesAllocation of ResourcesAllocation of ResourcesAllocation of Resources

Several approaches to consider…Several approaches to consider…– All patients could receive the same amount of All patients could receive the same amount of

attention.attention.– Patients could receive resources based on need.Patients could receive resources based on need.– Patients could receive what someone has Patients could receive what someone has

determined they’ve earned.determined they’ve earned.

Triage is a common field activity Triage is a common field activity that demonstrates one method of that demonstrates one method of

allocating scarce resources.allocating scarce resources.

Obligation to Provide CareObligation to Provide Care

A paramedic…A paramedic…– Has a responsibility to help others. Has a responsibility to help others. – Is obligated to provide care without regard to the Is obligated to provide care without regard to the

ability to pay or other criteria.ability to pay or other criteria.– Has a strong ethical obligation to help others even Has a strong ethical obligation to help others even

while off-duty.while off-duty.

TeachingTeachingTeachingTeaching

Two possible ethical questions are raised Two possible ethical questions are raised when a student is caring for patients:when a student is caring for patients:– Whether or not patients should be informed that a Whether or not patients should be informed that a

student is working on them;student is working on them;– How many attempts a student should be allowed to How many attempts a student should be allowed to

have in performing an intervention.have in performing an intervention.

To avoid problems…To avoid problems…

Clearly identify students as such.Clearly identify students as such. The preceptor should, whenThe preceptor should, when

appropriate, inform the patient of theappropriate, inform the patient of the student’s presence and obtain thestudent’s presence and obtain the patient’s consent.patient’s consent.

Take the student’s experience andTake the student’s experience and skill level into account and have a skill level into account and have a pre-determined limit identified for thepre-determined limit identified for the number of attempts at a procedure.number of attempts at a procedure.

Professional RelationsProfessional Relations

A paramedic answers to theA paramedic answers to the patient, the physician medicalpatient, the physician medical director, and to his employer.director, and to his employer.

Sometimes conflict arisesSometimes conflict arises out of such relationships.out of such relationships.

Know your policies…andKnow your policies…and communicate.communicate.

ResearchResearch

EMS research is only in its infancyEMS research is only in its infancy but is essential to the advancementbut is essential to the advancement of EMS.of EMS.

Strict rules and guidelines must beStrict rules and guidelines must be followed when conducting patientfollowed when conducting patient care-related studies.care-related studies.

Gaining the patient’s consent isGaining the patient’s consent is paramount.paramount.

QUESTION QUESTION

Your partner contacts a former patient to Your partner contacts a former patient to ask for a date using the phone number from ask for a date using the phone number from the patient care report. the patient care report.

What would you tell your partner and What would you tell your partner and supervisors?supervisors?

Is this immoral? Is this immoral? Is this unethical? Is this unethical? Is this illegal?Is this illegal?

QUESTION 1 QUESTION 1

1.1. What would you tell your partner and What would you tell your partner and supervisors?supervisors?

2.2. Is this immoral? Is this immoral?

3.3. Is this unethical? Is this unethical?

4.4. Is this illegal?Is this illegal?

QUESTION 2 QUESTION 2

You arrive at a home where a 3 month old You arrive at a home where a 3 month old baby who has obviously been dead for baby who has obviously been dead for several hours. The mother is hysterical and several hours. The mother is hysterical and begging you to “Please, do something”.begging you to “Please, do something”.

QUESTION 2 QUESTION 2

What would you do?What would you do?

Is this ethical?Is this ethical?

QUESTION 3 QUESTION 3

The BioTel physician gives you orders for a The BioTel physician gives you orders for a drug that you feel is inappropriate. You drug that you feel is inappropriate. You explain your concern over the radio and the explain your concern over the radio and the physician still insists that you give the physician still insists that you give the medication. medication.

QUESTION 3 QUESTION 3

What would you do?What would you do?

Is this ethical and legal?Is this ethical and legal?

QUESTION 4QUESTION 4

You and your partner are caring for a 55 You and your partner are caring for a 55 year old patient who is in respiratory arrest. year old patient who is in respiratory arrest. You have called for assistance and are told You have called for assistance and are told it will be 10 minutes before assistance it will be 10 minutes before assistance arrives. The patient is intubated and is arrives. The patient is intubated and is stable as long as you ventilate regularly. stable as long as you ventilate regularly. You are preparing for transport when You are preparing for transport when suddenely your partner collapses and is suddenely your partner collapses and is pulseless. pulseless.

QUESTION 4QUESTION 4

What would you do?What would you do?

Is this ethical and legal?Is this ethical and legal?

QUESTION 5QUESTION 5

Your are caring for a patient with an isolated Your are caring for a patient with an isolated extremity fracture and BioTel refuses to extremity fracture and BioTel refuses to permit you to give the patient pain permit you to give the patient pain medication. medication.

What would you do?What would you do? Is this ethical and legal and moral?Is this ethical and legal and moral?

QUESTION 5 QUESTION 5

What would you do?What would you do?

Is this ethical and legal and moral?Is this ethical and legal and moral?

QUESTION 6 QUESTION 6

You are transporting a patient and her physician to You are transporting a patient and her physician to the hospital. The Patient was at an out patient the hospital. The Patient was at an out patient surgery center where she just underwent a surgery center where she just underwent a procedure. On the way to the hospital you notice procedure. On the way to the hospital you notice that the patient’s breathing is shallow and slow. that the patient’s breathing is shallow and slow. You verbalize the need to ventilate and you You verbalize the need to ventilate and you quickly begin to gather the appropriate equipment. quickly begin to gather the appropriate equipment. The physician strongly disagrees with you. The physician strongly disagrees with you.

QUESTION 6 QUESTION 6

What would you do?What would you do?

Is this ethical and legal?Is this ethical and legal?

QUESTION 7QUESTION 7

You are transporting a patient and her physician to You are transporting a patient and her physician to the hospital. The Patient was at an out patient the hospital. The Patient was at an out patient surgery center where she just underwent a surgery center where she just underwent a procedure. On the way to the hospital you notice procedure. On the way to the hospital you notice that the patient’s breathing is shallow and slow. that the patient’s breathing is shallow and slow. You verbalize the need to ventilate and you You verbalize the need to ventilate and you quickly begin to gather the appropriate equipment. quickly begin to gather the appropriate equipment. The physician strongly disagrees with you. The physician strongly disagrees with you.

Question 7Question 7

What would you do?What would you do?

Is this ethical and legal?Is this ethical and legal?

QUESTION 8 QUESTION 8

Your cousin’s daughter is pregnant. She is Your cousin’s daughter is pregnant. She is vomiting and is obviously dehydrated. Your vomiting and is obviously dehydrated. Your cousin does not have any health insurance cousin does not have any health insurance and asks you to get some supplies from and asks you to get some supplies from work in order to start an IV and give her work in order to start an IV and give her something for her vomiting. something for her vomiting.

QUESTION 8 QUESTION 8

What would you do?What would you do?

Is this ethical and legal? Is this ethical and legal?

QUESTIONS QUESTIONS