Ethics in Emergency Medicine: Amalia Muhaimin

Ethics in Emergency Medicine
Amalia Muhaimin
Department of Public Health, Division of Bioethics School of Medicine, Faculty of Medicine and Health Sciences Universitas Jenderal Soedirman
Ethical issues related to emergency medicine:

1. Informed Consent and Refusal
2. Patient Decision Making Capacity

3. Treatment of Minors 4. Advance Directives
5. Limiting Resuscitation
6. Futility 7. Confidentiality
8. Truth Telling and Communication

9. Compassion and Empathy 10. Moral Issues in Disaster Medicine
1. Informed consent & refusal

Define the emergency rule
Describe the circumstances under
which a physician may treat a patient against his or her will
The Emergency Rule

1. Patient unconscious or otherwise incapable of consenting exception to informed consent 2. Limited time emergency services operate under the moral imperative of beneficence, acting in the best interests of the patient.
3. In time of life threatening crisis physician's duty to do that which the occasion demands, even without the consent of the patient.
How urgent?
How urgent a situation is depends
upon: - consequences of a delay in rendering treatment, or - consequences of a failure to render any treatment at all.
Informed refusal
1. Patients with decision making capacity (capacity) have a right not to consent to care.
2. The elements of a valid, informed refusal are the same as consent: capacity & comprehension of information (risks & harm)
3. Refusal of care may conflict with physicians judgment & recommendation emphasize the risks & consequences
4. Both consent and refusal must be made voluntary, without coercion/duress. 5. Physicians should provide treatment despite: - a verbal refusal in patients with no capacity, or - life threat is so acute no time to assess refusal. 6. When patients do not have capacity benefit must outweigh the potential risk of harm
Case 1:
25 y.o. with head injury due to traffic
accident, GCS 15, mouth & nose bleeding, mandibular fracture Doctor suggests head CT-scan, receives informed consent from patient, but disapproved by hospital due to administrative matter (who will pay?)
2. Patient Decision Making Capacity

Define decision making capacity Contrast medical interpretations of
decision making capacity with the legal definition of competence. List the ways decisions can be made when a patient lacks decision-making capacity
The Medical Concept of Decision Making Capacity

All adult patients unless there is evidence
obtained by history, behavior, or physical examination The determination of decision making capacity requires that: 1. The patient appreciates he/she has the power to make 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 is consistent with his or her life values or goals.
Level of capacity
The degree/level of decision-making capacity varies with the degree & probability of risk, benefit, & patient's decision to consent/refuse.
The greater the risk the more exacting
the standard of capacity A patient might need a low level of capacity to consent to a procedure with substantial benefits and minimal risks, but a high level of capacity to refuse the same
The Concept of Legal Competence?

Each state may have slightly different
criteria for the determination of competence How about Indonesia??
When a Patient Lacks Decision-Making Capacity

How should medical decisions be
made? depends on: - the speed with which the decision must be made - what information about patient preferences is available
When patients previously expressed
wishes are known, based on the
Case 2:
60 y.o. referred from private hospital with
(suspect of) CRF (7 days of hospitalization, askeskin) Arrived in E.R. unconscious (somnolen, GCS 12), suspect of metabolic disorder Latest lab results reveal normal, doctors advise head CT-scan to find etiology & establish diagnosis Wife disagrees (wishes for homecare) but children agrees to go on
3. Limiting Resuscitation
Define "Do Not Resuscitate Order" (DNR
order). Explain conditions which must be present to withhold resuscitation Explain the role of family and significant others in decisions about resuscitation.
Withhold & withdraw?

Withholding & withdrawing: no moral
difference Indeed a difference, but not a moral one in itself There can be a moral difference in some situations Creates potential difficulty for families, as well as for physicians
It is legally and ethically acceptable to
withhold resuscitation attempts on patients who have expressed clear wishes (Indonesia?)
Challenge communication means of
communication must be legally, ethically, and medically sound (ex: form with patient & physician signature, patient arm-band, etc.)
Emergency setting presents difficulties
patient's wishes, medical condition, and prognosis are usually unknown.
If there is doubt resuscitative efforts
should be initiated.
The decision to resuscitate must be an
immediate yes or no decision.

"Slow codes," suboptimal effort, or
delayed intervention are never medically or ethically acceptable.
Case 3:
30 y.o. in coma due to traffic accident,
GCS 4 Develops respiratory failure doctor suggest patient put on NRM / ventilator After 3 hours parents decide to stop life support & bring home their child on whatever condition
Reference
Blank R., Merrick J. (ed). End of Life Decision
Making. A Cross-National Study. Cambridge: MIT Press, 2005 Peterson L. Workshop and Panel Discussion on End of Life: Developing palliative care unit & strengthening hospital ethics committee. Yogyakarta, 15-17 January 2008 SAEM Ethics Committee Ethics Curriculum for Emergency Medicine Residencies,1994

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Ethics in Emergency Medicine

Ethical issues related to emergency medicine:

2. Patient Decision Making Capacity

8. Truth Telling and Communication

1. Informed consent & refusal

which a physician may treat a patient against his or her will

The Emergency Rule

2. Patient Decision Making Capacity

The Medical Concept of Decision Making Capacity

The Concept of Legal Competence?

criteria for the determination of competence How about Indonesia??

When a Patient Lacks Decision-Making Capacity

wishes are known, based on the

Withhold & withdraw?

It is legally and ethically acceptable to

patient's wishes, medical condition, and prognosis are usually unknown.

If there is doubt resuscitative efforts

immediate yes or no decision.

delayed intervention are never medically or ethically acceptable.

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