Ethical and Legal Concerns

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There are unique ethical and legal obligations of the Emergency Room Physician. Commonly faced issues include patient “dumping”, organ donation, and Do-Not Resuscitate orders. These issues have ethical and legal considerations for the Emergency Room Physician in regards to their responsibilities and actions.

The ethical right for individuals to have access to health care already has a form of legal binding within the United States as seen in the Emergency Medical Treatment and Active Labor Act. “In 1986, Congress passed the Emergency Medical Treatment and Active Labor Act (EMTALA), which forbids Medicare-participating hospitals from “dumping” patients out of emergency departments” (Pozgar, 2010, p. 221).

The act provides that: In the case of a hospital that has a hospital emergency department, if any individual (whether or not eligible for benefits under this sub- chapter) comes to the emergency department and a request is made on the individual’s behalf for examination or treatment for a medical condition, the hospital must provide for an appropriate medical screening examination within the capability of the hospital emergency department, including ancillary services routinely available to the emergency department, to determine whether or not an emergency medical condition …

exists (Pozgar, 2010, p. 221). Through this Act, a form of guaranteed access does exist. “Federal and state statutes impose a duty on hospitals to provide emergency care. The statutes require hospitals to provide some degree of emergency service. “If the public is aware that a hospital furnishes emergency services and relies on that knowledge, the hospital has a duty to provide those services to the public” (Pozgar, 2010, p. 271). Unfortunately, this has caused issues in Emergency Room overcrowding.

While the Emergency Room Physician is obligated to “emergency care”, “Realistically, when hospitals live up to this requirement, it is difficult for them to confine the care they provide to the emergency room. Patients who are not kept on for further acute care outside the emergency room will likely just show up again, incurring more emergency room care for which they are not insured. Because of the EMTALA, therefore, much more than emergency room care is provided regardless of ability to pay” (Menzel, 2011, p. 84).

“Hospitals are not only required to care for emergency patients, but they also are required to do so in a timely fashion” (Pozgar, 2010, p. 272). “Hospitals are expected to notify specialty on-call physicians when their particular skills are required in the emergency department. An on-call physician who fails to respond to a request to attend a patient can be liable for injuries suffered by the patient because of his or her failure to respond” (Pozgar, 2010, p. 271). Under the doctrine of Respondeat Superior, hospitals are also liable for the actions of physicians working or on-call in their emergency department.

The need for organ donations creates another ethical dilemma for Emergency Room Physicians. “Obtaining organs from emergency room patients has long been considered off-limits in the United States because of ethical and logistical concerns” (Stein, 2010). The shortage of organs available for transplant has caused many patients die while waiting. A pilot project from the federal government “has begun promoting an alternative that involves surgeons taking organs, within minutes, from patients whose hearts have stopped beating but who have not been declared brain-dead” (Stein, 2010).

“The Uniform Determination of Death Act (UDDA) and its state counterparts require the “irreversible” cessation of the functions of either (i) the entire brain or (2) the heart and lungs before a person can be considered dead” (Harrington, 2009). The ethical question arises for the Emergency Room Physician “about whether organ preservation and removal might begin before patients are technically dead, and because of fears that doctors might not do everything possible to save patients and may even hasten their deaths, to increase the chance of obtaining organs” (Stein, 2010).

The complexity of the ethical concerns of this issue extends to the Do-Not-Resuscitate orders, “particularly with controlled donors who have a constitutionally protected right to withdraw life-sustaining care” (Harrington, 2009). The final issue being addressed which holds both ethical and legal conditions, is the Do-Not-Resucitate (DNR) order. “A DNR order is a written medical order that documents the patient’s wishes regarding resuscitation and, more specifically, the patient’s desire to avoid CPR” (Payne & Thornlow, 2008).

An Emergency Room Physician may be unaware of a DNR order, or the DNR order may not be in the hospital’s medical record. Also, during emergency care, an Emergency Room Physician most likely will not have the time to review the existence of a DNR order. “This example highlights the challenges in communicating vital information across health care sites and among health care providers. To meet these challenges, several states have enacted legislation requiring the portability of do-not-resuscitate (DNR) orders” (Payne & Thornlow, 2008). The portable DNR would travel with the patient.

“Several states have established guidelines for use of portable DNR orders, including Florida, Iowa, North Carolina, Ohio, Maine, Massachusetts, and Vermont” (Payne & Thornlow, 2008). These states require that emergency medical services and emergency care workers honor the directives statewide. DNR orders is not something that should be discussed during urgent critical care, but should be discussed over time. Provider, patient, and family members should discuss the terms and interpretations of such orders during times when the patient is stable.

The unique ethical and legal obligations commonly faced by Emergency Room Physician Commonly include patient “dumping”, organ donation, and Do-Not Resuscitate orders. The Emergency Medical Treatment and Active Labor Act was enacted to prevent the ethical issue of patient “dumping”. The Uniform Determination of Death Act provides stipulations in the ethical issues of emergency room organ donations. Written medical orders of Do-Not-Resuscitate provide autonomy to patients, but are not always accessible to the Emergency Room Physician.

The responsibilities and actions of the Emergency Room Physician need to reflect the ethical and legal considerations that are found in an emergency room setting. References Harrington, M.. (2009). The Thin Flat Line: Redefining Who is Legally Dead in Organ Donation After Cardiac Death. Issues in Law & Medicine, 25(2), 95-143. Retrieved August 28, 2011, from Research Library. (Document ID: 1920050551). Menzel, Paul T. (2011) “The Cultural Moral Right to a Basic Minimum of Accessible Health Care. ” Kennedy Institute of Ethics Journal 21. 1: 79-119. Project MUSE. Web. 9 May. 2011.

. Payne, J. , & Thornlow, D.. (2008). Clinical Perspectives on Portable Do-Not-Resuscitate Orders. Journal of Gerontological Nursing, 34(10), 11-6. Retrieved August 29, 2011, from ProQuest Health and Medical Complete. (Document ID: 1570040851). Pozgar, G. D. (2010). In Legal and Ethical Issues for Health Care Professionals (2nd ed. ,). Sudbury, MA: Jones and Bartlett Publishers. Stein, Rob (2010, March 21). In ER, new ethics dilemma arises :Test of rapid organ donations raises controversy. Boston Globe,p. A. 19. Retrieved August 25, 2011, from ProQuest Newsstand. (Document ID: 1988545611).

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