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Plenty of ethical questions arise before patients reach the hospital
EMS providers find ethical dilemmas in the field
Medical ethics issues arise before some patients ever reach a hospital or emergency room, as paramedics, emergency medical technicians (EMTs), and the physicians who serve as medical directors for emergency medical services (EMS) grapple with resuscitation, triage, and consent issues.
"I responded to [Hurricane] Katrina, and that was the largest peacetime triage in history," says Bernard Heilicser, DO, MS, FACEP, an emergency physician and ethics chair at Ingalls Hospital in Harvey, IL, and medical director of the South Cook County (IL) EMS system. "I triaged 150 patients in an hour, and of those, 32 were in fluid overload due to not being able to get dialysis. We had only two or three dialysis spots — which patients get them?
"EMS makes those decisions, on a smaller scale, all the time," he continues. "Who is going to get the heavy meds and who isn't? We had a situation where there was a police chase and the guy slams into a police car that was blocking the road. The cop gets an open femur fracture, and the [fleeing suspect] hit the windshield with his head. Who gets the helicopter? It's the one who's sickest, but is that always the most ethical decision?"
Paramedics and EMTs, operating under the direction of standing orders directed by physicians, are performing more and more sophisticated procedures in the field — in the case of paramedics, invasive procedures that not many years ago were not performed outside a hospital. Depending on who you ask, this increased sophistication has either generated more ethical issues or reduced them.
"In terms of triaging, we can do more in the field. At the paramedic level, they can intubate, do pericardial centesis, do more invasive procedures," says Heilicser. "If they can do more, and now there's a mass casualty event, they have to face the question of, 'Do I take the time to resuscitate this one critically injured person, or do I let him go and treat 10 others in the time and with the limited resources I have?' With increased sophistication come more questions of what can they do."
But knowledge is power, says Jerry Johnston, BA, EMT-P, EMS director for the Henry County (Iowa) Health System and president of the National Association of Emergency Medical Technicians (NAEMT).
"With increased sophistication comes increased training and didactic knowledge and clinical knowledge, and the medical director guides the process," Johnston suggests. "So the more sophisticated systems probably deal with fewer ethical questions than others with fewer resources."
But the issue of triage — doing the greatest good for the greatest number — can go against the grain of EMS providers, he admits, because their instinct and training is to treat the worst-injured first.
"It's an ongoing, evolving process, to hone triage skills," Johnston adds. "In an event like a plane crash, with 150 to 200 people spread over an area, if a person has an injury that is incompatible with life, you pass them over. I know there have been rescuers who have had post-traumatic stress disorder and other issues from having to make those decisions."
Terminating resuscitation a controversial issue
Before Sept. 11, 2001, Heilicser says prehospital ethics "was a hot topic. I was giving ethics lectures to anyone who would listen."
In the years since the terrorist attacks that changed how Americans and American public safety think about homeland security, Heilicser says he's asked more often to talk about EMS response to weapons of mass destruction and other terror threats.
But issues like prehospital DNR orders and when to terminate resuscitation in the field remain hot-button topics.
Terminating resuscitative efforts has been much debated recently among EMS systems in the United States, with many establishing set rules for initiating resuscitation and transport to the emergency room with lights and sirens running. Public safety is one concern; primarily, however, EMS leaders say the decision to set limits is based on the reality of survival of people who go into cardiac arrest outside the hospital.
Most patients do not survive out-of-hospital cardiac arrest, so a 2005 study reported in Prehospital Emergency Care1 reviewed data for 501 adults who experienced nonhypothermic cardiac arrest and were transported to two urban emergency departments.
Of those 501, 87% died in the emergency room, 10% died in the hospital, and 2% survived to discharge.
"The preponderance of evidence is that if you don't resuscitate within a certain time, then resuscitation is futile — we know this," says Johnston.
"But at what point do you say, 'No more?' When do you say, 'We're going to stop, we're not going to transport this person just so the physician can declare them dead at the hospital?'"
Johnston recalls that when he started working in EMS in the late 1970s, everyone received full-out resuscitative efforts, regardless of the likelihood of success.
"We did CPR for hours and hours and hours, with the hope that you could eventually produce a heartbeat. And with very rare exceptions, usually only with hypothermia in cold-water drownings, that never happened," he says.
Decades of experience like this, Johnston says, has led some systems to establish protocols for not transferring patients and limiting resuscitative efforts.
"They say that in specific situations, we are not going to transfer; we will try for 20 minutes, and then after that we aren't going to transport," he says.
Informing families, bystanders
Johnston and Heilicser say the trend to establish clearer guidelines for when to initiate and terminate prehospital resuscitation leads to another issue — paramedics and EMTs who must tell family and bystanders that they are not going to continue efforts.
"That turns the EMT or paramedic into a family provider, grief counselor, and social worker for the family," he says. "It's not an easy decision, and if you're going to make that decision then the personnel in the system need to undergo more training in those areas than they normally have."
Making a difficult ethical decision even harder, Johnston asserts, is the unrealistic expectations many laypeople have about what prehospital medicine can accomplish.
"The public expectation is that EMS comes, and everyone is saved," he says. "Television fuels that perception, but the very best EMS systems only save one-third or so of people in cardiac arrest, in terms of them leaving the hospital in the state they were in prior to the event. And I think that's the approach we should take — sure, we can resuscitate them and get them into the ICU, but we need to look at how many are leaving the hospital in a state similar to what they were in prior to the event, and it's not very many."
Heilicser says that public perception is why EMTs and paramedics start CPR on cardiac arrest victims in cases that they know are futile.
"A lot of times it's futile and it's done just for show [for the benefit of family members], which we all know," he adds.
Johnston says that in his role as NAEMT president he has talked to systems that are successfully establishing tighter protocols for out-of-hospital resuscitation and transport, and what makes them successful is the additional training the systems provide their EMTs and paramedics.
"They are getting their people additional training in grief counseling, really trying to explain what's going on," he relates. "They are training people how to say, 'We're doing all we can, but it really doesn't look very good,' and then dealing with the after-effects, and that's not something we have ever really done as an industry."
DNRs a two-edged sword
Prehospital DNR orders, the out-of-hospital version of DNRs that instruct physicians that someone does not want extraordinary measures taken to resuscitate or extend life, provide guidance and add to the ethical pull felt by EMS personnel, Heilicser says.
"DNRs were the biggest issue for a while — understanding advance directives in the field," he explains. "A lot of times [EMS personnel] get there and there's a contradiction — the patient looks workable but there's an advance directive that says not to. Or the reverse: The patient is someone who it's futile to try, but there's no DNR."
Paramedics, he says, "face some gut-wrenching cases — the 90-year-old ladies about to code in a nursing home, with no advance directive. It's very difficult to crack the ribs in people you feel pretty certain are futile, and paramedics are torn by that. The antithesis is the patient they would like to resuscitate, but have an advance directive telling them not to."
Heilicser says here, too, education is key.
"There are high-profile cases involving DNRs and advance directives, like the Terri Schiavo case, but how many people are actually getting DNRs, living wills, and powers of attorney for health care?" he asks. "Those are issues not covered that intensely in EMS training, and sometimes when they call in to the hospital, the nurse or doctor they talk with might not be all that familiar, either."
Other issues concern EMS and doctors
The Emergency Medical Treatment and Active Labor Act (EMTALA), enacted to protect against patients being denied emergency medical care, is routinely being violated by emergency departments that are at such crisis levels that they are on bypass status day after day, forcing ambulances to travel to other, possibly more distant, hospitals.
"I'll go in tonight, and we'll be on bypass, with 10 people waiting around the desk — not waiting to be seen, but waiting at the desk [to check in]," Heilicser says. "People aren't paying attention to the Institute of Medicine [report] saying we're at the breaking point. Isn't it an EMTALA violation when a patient wants to come to your hospital, but you have to turn them away?"
The Institute of Medicine (IOM), in its 2006 report, Emergency Medical Services at the Crossroads,2 points out what emergency room personnel and EMS providers have long known — more and more people are using 911 as their gateway to health care.
Also, the IOM noted that there is substantial variation nationwide in how medical oversight and review of EMS systems are conducted. In some systems, physicians with little or no training and experience in out-of-hospital medical care provide EMS direction, and there currently is no emergency medicine subspecialty of EMS. The IOM report concludes with a recommendation that the American Board of Emergency Medicine create a subspecialty certification in EMS for physicians who provide medical direction to prehospital providers.
Documenting consent, refusal
EMS leaders say one important piece of business that frequently gets lost in the urgency of an emergency call is proper documentation of informed consent and informed refusal.
"How do you truly get an informed refusal?" asks Heilicser. "It's estimated that 20% of paramedic calls end up in refusal, but are paramedics truly telling the risks of this decision, or is it that the paramedics are in a hurry to get going to the next call?"
Besides being good medicine to ensure a patient knows the risks of refusing care, a true informed refusal can make a big professional and financial difference later.
"I don't think they fully appreciate how, down the road, that little bit of documentation could preserve a lot of grief if they end up in court," adds Heilicser. "And sometimes you see them letting a family member sign off on the refusal, but are they really determining if that family member is the appropriate surrogate?"
Medical directors for EMS should make efforts to address ethical issues and point out potential ethical conflicts before they arise in the field and force emergency personnel and the doctors they are on the phone with to "shoot from the hip," Heilicser suggests.
"Deal with them now and think about them now, so then when they occur, you have the knowledge and you know how to do the right things because you've addressed them in an academic environment beforehand," he continues. "Teach the doctors, nurses, and paramedics these things in a principled, focused manner, emphasizing the basic principles of ethics — beneficence, nonmalfeasance, justice, and autonomy — and they will be prepared, rather than finding themselves wondering, 'How will I deal with this?'"
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