Emergency Medicine and the Ethical Dilemmas

Picture this scenario: You are working in the emergency room of a public hospital where the inflow of patients is higher than the available beds. You are treating an elderly man who is breathless and cyanosed. While you assess whether he has chronic obstructive pulmonary disease or heart failure, he becomes drowsy and starts gasping. You quickly intubate him with some difficulty, prolonging his period of hypoxia, and put him on ventilator support. You then get a phone call from a senior consultant in the hospital that an important social activist is about to arrive with chest pain and will need to be admitted.

You are directed to arrange a bed for him. The activist arrives; you walk up to him and make him comfortable on an examination couch. Your clinical acumen tells you that he is suffering from a benign disorder and does not need emergency attention. His aides are anxious and demanding. A comatose woman is now brought in. You find out that she has a fulminant, post-par tum illness for the previous three days. She is very sick and toxic. You have one vacant bed and three patients. What would you do (Goel, Aggarwal, 2006)? Emergency physicians have unique ethical issues in their practice of medicine.

Working in the emergency room is the most unique place to work, because of the several different scenarios that can happen there. It sometimes involves quick scenarios, unexpected patients, and a special sense of urgency to most of the cases. These physicians have to make quick decisions, and as a result, have many ethical issues to deal with. The unique ethical perspectives encountered by the physician have not been dealt with adequately in most of the literature pertaining to medical ethics. The patient may come to the emergency department for treatment not because of his choice but due to the urgency and acuteness of the problem.

The physician would most likely not have a pre-existing physician-patient relationship with this patient. For this patient, the ability to pay is not an issue considered up front. Emergency treatment will be rendered first as deemed appropriate. Decision making time for any procedure he may require is short. Decisions are often being made to ‘play safe’, many times erring on the side of caution. In this paper, we will look at the ethics of the emergency room more closely, and examine what these physicians and staff have to deal with on a daily basis.

When a patient comes to the ER, depending on the situation, there is little time to get basic information from them. Decisions have to be made quickly sometimes, and most often goes by the symptoms that are present rather than the patient’s health history. This makes the concept of being ethical a challenge to these physicians. The American College of Emergency Physicians have developed a unique ethic guide for the emergency room, the Principles of Ethics for Emergency Physicians. It addresses the unique duties that an emergency room physician has.

It states that the unique setting and goals of emergency medicine give rise to a number of distinctive ethical concerns. Among the special moral challenges confronted by emergency physicians are the following: First, patients often arrive at the emergency department with acute illnesses or injuries that require immediate care. In these emergent situations, emergency physicians have little time to gather additional data, consult with others, or deliberate about alternative treatments. Instead, there is a presumption for quick action guided by predetermined treatment protocols.

Second, patients in the emergency department often are unable to participate in decisions regarding their health care because of acute changes in their mental state. When patients lack decision-making capacity, emergency physicians cannot secure their informed consent to treatment. Third, emergency physicians typically have had no prior relationship with their patients in the emergency department. Patients often arrive in the emergency department unscheduled, in crisis, and sometimes against their own free will.

Thus, emergency physicians cannot rely on earned trust or on prior knowledge of the patient’s condition, values, or wishes regarding medical treatment. The patient’s willingness to seek emergency care and to trust the physician is based on institutional and professional assurances rather than on an established personal relationship. Fourth, emergency physicians practice in an institutional setting, the hospital emergency department, and in close working relationships with other physicians, nurses, emergency medical technicians, and other health care professionals. Thus, emergency physicians must understand and respect institutional regulations and inter-professional norms of conduct.

Fifth, in the United States, emergency physicians have been given a unique social role and responsibility to act as health care providers of last resort for many patients who have no other feasible access to care. Sixth, emergency physicians have a societal duty to render emergency aid outside their normal health care setting when such intervention may save life or limb. Finally, by virtue of their broad expertise and training, emergency physicians are expected to be a resource for the community in pre-hospital care, disaster management, toxicology, cardiopulmonary resuscitation, public health, injury control, and related areas.

All of these special circumstances shape the moral dimensions of emergency medical practice (Amer College of Emergency Physicians, 2010). There are many more issues that physicians in ER’s have to deal with, so they have their own set of ethics and principles that they follow. Obviously, the ultimate goal is to treat patients as soon as possible, with the most urgent cases being first. One of the most prevalent issues in working in an emergency room is the order in which the patients are seen. This order is not determined by a first-come, first-serve basis.

Rather, it is determined by the triage nurses, who decide which patients are the most critical cases. These patients are seen first. If a patient’s ailment is not as serious, they can be waiting for quite a long time in the waiting room to be seen. The doctors and staff that work in these departments have to have a special compassion for the patients that come in. Here, all that should matter is the medical needs of the patients. The ability to pay goes by the wayside here, as everyone who comes into an ER should be treated with respect and dignity.

Intake clerks and triage nurses need to be efficient, as well as caring and kind. Every patient thinks that their ailment is urgent, to them it is. It is the job of the triage nurses to figure out which cases are most urgent, and which cases can wait. Of course, if an ambulance comes in with someone critically injured, then everything else ceases while this patient is immediately attended to. The staff needs to be able to adapt to change quickly, at the drop of a hat, while at the same time still maintaining the highest regard for patient care.

Because of the high paced happenings that occur in an emergency room, there is a higher risk of malpractice suits being brought against the physicians and staff here. A missed symptom by the triage nurses or doctors, and just like that, a patient is injured. A study published in the Archives of Internal Medicine indicated that problems with delays in emergency room treatment are worsening across the country. Researchers from the University of California, San Francisco, found that the number of patients being seen in a timely manner is decreasing by about 0.

8 percent per year, with just over 75% of patients being seen within a safe time frame. The researchers said the worsening problem could cost lives (AboutLawsuits. com, 2010). These statistics dictate that the triage nurses and the physicians need to be especially attentive to the flow of patients coming into the ER. They need to make sure they examine patients thoroughly the first time, to ensure that the patient is caused no harm. There have been several cases of malpractice in the ER due to not so thorough examinations at the triage stage, and the patient wait times.

There are a number of recommendations that have been suggested to decrease wait times, some of which are: condensing the number of questions asked by triage nurses, and having those nurses assign the patient to their next nurse, having patients see the doctor and nurse at the same time after passing through triage, instead of one after the other, equipping emergency rooms with bedside supplies that address the most common reasons for emergency room visits, and having information such as patient identification and insurance collected at bedside, once the patient is already being seen (AboutLawsuits.com, 2010).

In conclusion, the emergency room and its staff have some very unique ethical and legal issues that they have to deal with. In order for them to abide by them, they have to be efficient, accurate, and prompt. At the same time, they must be kind, caring and attentive to the overflowing load of patients that they see on a daily basis. The main thing they need to remember is that they are most of patient’s only hope at the time for treatment. They need to be very careful that they abide to the ethical standards that they set in place for them. Several lives can depend on them.

References.

American College of Emergency Physicians. (2010). Principles of Ethics for Emergency Physicians. Retrieved December 5, 2010 from http://www. acep. org/content. aspx? id=29144 . Sandra H Johnson. (2005). The Social, Professional, and Legal Framework for the Problem of Pain Management in Emergency Medicine. The Journal of Law, Medicine & Ethics, 33(4), 741-760. Retrieved December 6, 2010, from Research Library. (Document ID: 989446671). http://proquest. umi. com/pqdwebdid=989446671&sid=3&Fmt=3&clientId=74379&RQT=309&VName=PQD ACEP News. (2007). Withdrawing Treatment: An Ethical Perspective.

ACEP News, April 2007. Retrieved December 6, 2010 from http://www. acep. org/content. aspx? id=26490&terms=ethics. Goel, A. and Aggarwal, P. (2006). Making choices in an emergency room. Indian J Med Ethics, Jul-Sep; 3(3). Retrieved December 5, 2010 from http://www. issuesinmedicalethics. org/143ms105. html. AboutLawsuits. com. (2010). Emergency Room Malpractice Lawsuits Filed Over Death from Delays. AboutLawsuits. com, January 4, 2010. Retrieved December 5, 2010 from http://www. aboutlawsuits. com/emergency-room-malpractice-lawsuits-over-waiting-room-delays-7515/.

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