New Approaches for Ethically Challenging ED Cases
Ethically challenging cases happen all the time in the ED. But unlike in the ICU, ED clinicians hardly ever consult with ethicists about these difficult cases.
“Common issues are end-of-life decisions, refusal of medical care, consent for medical care, issues involving minors, patients who lack decisional capacity, and mental health issues,” says Catherine A. Marco, MD, FACEP, professor in the department of emergency medicine at Wright State University in Dayton, OH.
Ethics consultants can help clinicians weigh the options and make the best decisions. However, time does not always allow for this. “I have not personally seen ethics consultation done in the ED,” Marco reports. “Many decisions must be made expeditiously.”
Ethicists can provide education about ethical and legal issues that can help emergency physicians manage ethical dilemmas in the ED. “Emergency physicians should be knowledgeable about federal and state law, principles of medical ethics, and institutional policies,” Marco offers.
All too often, patients present to the ED in extremis, unable to indicate their wishes regarding resuscitation and end-of-life care — and without an advance directive. “One of the most frequent ethics concerns for emergency physicians [EPs] pertains to advance directives, or lack of them,” says Eileen F. Baker, MD, PhD, FACEP, medical director of the ethics curriculum at the University of Toledo College of Medicine.
Many patients have not discussed their end-of-life wishes with their family. “Under such circumstances, physicians are called upon to make difficult decisions that may have a great impact upon the care delivered not only in the ED, but in the hospital as well,” Baker observes.
Hospital ethics committees or their members may not be available for real-time consultation. Baker recently co-authored a paper on this topic.1 The following recommendations appeared in the paper:
• Members of hospital ethics committees should be available (either in person or via phone) to assist EPs with ethical quandaries. “Hospital ethics committees could develop an on-call list of their members for real-time consultation,” Baker suggests.
Alternatively, members of the EP’s group could engage colleagues with an interest in ethics to respond to partners in need.
• EPs should be involved with hospital ethics committees. “Volunteering to assist fellow EPs with ethical questions may provide an avenue if they are unable to commit to joining the committee,” Baker says.
• Professional organizations and societies should develop educational tools to better prepare EPs to address ethical issues. There are two common situations that can lead to unwanted care or ethical concerns, according to Jay M. Brenner, MD, FACEP, medical director of the ED at SUNY Upstate Medical University in Syracuse: When patients do not arrive with a do not resuscitate (DNR) status, and when patients ask to leave against medical advice (AMA).
For patients without DNR status, they might receive unwanted care because physicians are unaware of the patient’s preferences. Some patients are in extremis and cannot express themselves. “Either the documentation showing their DNR status or the patient’s surrogate decision-maker are not immediately available,” Brenner notes.
For patients who want to leave AMA, they might receive unwanted care if they are deemed to lack decision-making capacity to refuse treatment. “This may create ethical concerns among physicians who are reticent to letting them leave without indicated treatment,” Brenner explains.
A parent who refuses testing for a child with a fever is an equally challenging situation. “Ethicists might want to talk directly with the parent to uncover their rationale for refusal,” Brenner offers.
If it was consistent with their value system, then a clinician might recommend honoring the parent’s refusal as long as the child was reasonably safe and stable. If the parent’s reasoning seemed inconsistent, then the clinician might recommend pursuing legal options to protect the child, especially if he or she is medically unstable. “This scenario is further complicated by the COVID-19 pandemic and the need to identify those infected for public health reasons,” Brenner notes.
Brenner says the best way for ethicists to help is to be available. Some ethics consult services have extended their coverage from typical business hours to 24/7 during the COVID-19 pandemic. “This has helped quite a bit,” Brenner reports.
If a full-blown consult is not possible, ethicists can help discern the most critical aspect of a concern that a physician may express. “The ethicists can give a recommendation of what piece of information to seek out next to make a reasonable plan to navigate whatever the situation may be,” Brenner says.
This approach could work well if an ED patient refuses intubation. The patient may be too confused to reliably convince the EP he or she is capable of refusing the intervention. “An ethicist may be able to guide the emergency physician if they had not already thought of it to seek out a surrogate decision-maker,” Brenner says.
Quick, in-person responses; phone consults; and telemedicine consults all are possible approaches in the ED. “Rapid feedback, sometimes only highlighting relevant ethical principles and how to weigh them, can help physicians who are stressed by the complexity of an emergency,” Brenner says.
Training ED clinicians on ethical principles is a good way for ethicists to share their knowledge and expertise. “One of the most effective methods of teaching these principles is in the simulation lab, because it most closely simulates the actual stress of moral distress,” Brenner notes.
Depending on the quality of the acting and how realistic the mannequin, the “sim” lab can closely approximate reality. “This helps the lessons ‘stick’ for the emergency physician when they are in the emergency department,” Brenner adds.
- Baker EF, Geiderman JM, Kraus CK, Goett R. The role of hospital ethics committees in emergency medicine practice. J Am Coll Emerg Physicians Open 2020;1:403-407.
For emergency providers, time is precious. If a full-blown consult is not possible, ethicists can help discern the most critical aspect of a concern these clinicians may express. Quick, in-person responses; phone consults; and telemedicine consults all are possible approaches.
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