Moral/ethical dilemma concerning a pt's right to refuse.

[DwayneEMTP]

I have a question that has been nagging at me for a few weeks now...

70 y/o male with a history of IDDM.

Family calls stating that they talked to 'dad' on the phone 5 hrs past and that he seemed to be listening on the phone, but only made slurring, gurgling sounds in response to questions. After finishing their morning soaps, or whatever, they decided to go and check on him and find him unresponsive.

Upon my arrival I find the pt with eyes open/tracking slowly, snoring respirations, unable to speak. Another medic that has run on him regularly and recognizes the dispatched address calls to tell me that she transported him yesterday with a BGL of 480 (per hospital labs) and that he normally becomes hypoglycemic with a BGL below 80. She states that he will refuse transport when normal mentation is restored.

BGL now shows 72, all physiological markers make me comfortable that, at least partially, this is a hypoglycemic episode. Family verifies that he will refuse transport if 'woked up.'

My decision was to adjust his airway/suction which restored a patent airway, remove to my ambulance and deliver D50, slowly, enroute to the hospital. (Approx 5 min transport.)

I chose to remove this pt's ability to refuse, (or did I?) understanding that that would likely have been his decision based on these factors;

1. He had no support system at home. And that of his family was worse than unreliable.

2. He is obviously having life threatening issues in regards to controlling his IDDM.

3. This was his second life threatening crisis in two days, in fact I believe 4-5 in the last 10 days, despite having the County monitoring his "health and welfare."

4. The study I mentioned in another thread has convinced me that perhaps he is not normally mentating, despite appearances, when choosing to refuse.

5) My 'intent' was purely pt advocacy related without elements of 'not running him again today', 'lawsuit avoidance', etc.

So my questions...

1) Did I violate this persons 'right to refuse' by withholding necessary interventions until leaving his home?

2) Despite being in the best interest of my pt, was this an unethical/immoral thing to do?

And please, while telling me what a terrible medic I am, take a moment to justify your alternate decision(s).

Have a great day all.

Dwayne

[chbare]

Dwayne, if I read you correctly, you arrived on scene, ensured a patent airway with breathing and a pulse, and decided to load and go while performing additional interventions en-route. You did a "medical triage" as opposed to a "trauma triage" load and go.

Take care,

chbare.

[medic82942003]

works for me. you did good. Which means I agree with your tx of this pt. I remember im my first medic class they told us if you always act in the best interests of your pt you rarely will be wrong. ( did I say that right) Be safe.

Edited September 10, 2009 by medic82942003

[Mateo_1387]

1) Did I violate this persons 'right to refuse' by withholding necessary interventions until leaving his home?

Dwayne, I do not believe you violated his rights to refusal. First off your patient is not capable of refusing until he is treated. The way I see it, once the patient becomes alert, weather he is located in his home, in your ambulance or in your ER, he can then refuse care. Being in an ambulance does not mean he is forced to be seen by a doctor, provided he is alert and able to make competent decisions.

2) Despite being in the best interest of my pt, was this an unethical/immoral thing to do?

It sounds like the best interest of your patient is to reverse his immediate threat of hypoglycemia and transport him for evaluation by an ER Doc. I think the situation would become unethical/immoral if you patient becomes alert and competent, refuses farther medical care, and then you force him to endure the medical care.

And please, while telling me what a terrible medic I am, take a moment to justify your alternate decision(s).

I will give you my justification for calling you out as a terrible medic. You take advise from a hairy monkey located in Afghanistan on how to medically treat your patients. Nuff said...

Hehe

Edited for wordiness

Edited September 10, 2009 by Mateo_1387

[HERBIE1]

I have a question that has been nagging at me for a few weeks now...

70 y/o male with a history of IDDM.

Family calls stating that they talked to 'dad' on the phone 5 hrs past and that he seemed to be listening on the phone, but only made slurring, gurgling sounds in response to questions. After finishing their morning soaps, or whatever, they decided to go and check on him and find him unresponsive.

Upon my arrival I find the pt with eyes open/tracking slowly, snoring respirations, unable to speak. Another medic that has run on him regularly and recognizes the dispatched address calls to tell me that she transported him yesterday with a BGL of 480 (per hospital labs) and that he normally becomes hypoglycemic with a BGL below 80. She states that he will refuse transport when normal mentation is restored.

BGL now shows 72, all physiological markers make me comfortable that, at least partially, this is a hypoglycemic episode. Family verifies that he will refuse transport if 'woked up.'

My decision was to adjust his airway/suction which restored a patent airway, remove to my ambulance and deliver D50, slowly, enroute to the hospital. (Approx 5 min transport.)

I chose to remove this pt's ability to refuse, (or did I?) understanding that that would likely have been his decision based on these factors;

1. He had no support system at home. And that of his family was worse than unreliable.

2. He is obviously having life threatening issues in regards to controlling his IDDM.

3. This was his second life threatening crisis in two days, in fact I believe 4-5 in the last 10 days, despite having the County monitoring his "health and welfare."

4. The study I mentioned in another thread has convinced me that perhaps he is not normally mentating, despite appearances, when choosing to refuse.

5) My 'intent' was purely pt advocacy related without elements of 'not running him again today', 'lawsuit avoidance', etc.

So my questions...

1) Did I violate this persons 'right to refuse' by withholding necessary interventions until leaving his home?

2) Despite being in the best interest of my pt, was this an unethical/immoral thing to do?

And please, while telling me what a terrible medic I am, take a moment to justify your alternate decision(s).

Have a great day all.

Dwayne

Well done, Dwayne. I've done the same thing myself, for similar reasons. Clearly this is a social service as well as a medical issue, so better to get him to a place that has the resources that can at least attempt to address those needs then to release him back to the same situation, where he might not be so lucky the next time.

Immoral? Hardly. It was the most decent thing you could have done for this person. We are not supposed to be automatons out there- we need to make judgment calls and this one was spot on. The easy solution would have been to juice him up and get another refusal. That does him no good- and essentially ensures you will be back again in another day or 2, and the next time you might be too late.

[WolfmanHarris]

I suppose one could argue that delaying treatment was potentially unethical, but if I can be a utilitarian for a moment, you maximized the potential good for the patient with the least harm. Either way, I applaud the effort to break the cycle that can occur in some patients, especially poorly coping diabetics.

Recently I had to do a similar thing with an NIDDM pt. who's BGL had tanked. He was known to my partner, on scene PD (happened to be closest when the call came in), and the FD lookie-loos/scene obstructors (sorry I had particular issues with FD on this day) and it was apparent he was having issues with daily living. 1.0mg Glucagon SC later we were in the truck about to transport; my partner had returned to the home to chat with the wife and ensure she was taken care of and understood what was going on and my pt. began to come around. He wasn't fully lucid, but was already trying to convince me he was okay. I decided to walk the line on this and rather than seek clarification from my patient on what seemed to be a developing refusal, I played dumb and said, "Excellent sir, you had us worried for a moment. We're taking you to the hospital now to get checked out." I didn't encourage enunciation of his desire to refuse, nor did I say he had to go to the hospital. On route he became fully lucid but didn't quite verbalize a desire to refuse despite his repeated efforts to demonstrate he had control of his faculties, I continued to play dumb.

At the same time I realized that this patient was an ideal candidate for our Community Referral by EMS (CREMS) program and could benefit from homecare. But to enroll him I needed to obtain consent from this obviously proud, independent elderly gentleman. I could have asked in offical parlance for his consent, instead I said, "Sir, would you mind if I made a call to someone who could help ensure that we wouldn't need to come and visit you as often and interupt your morning?" He agreed.

My point is that sometimes we have to walk a fine line to advocate effectively for our patients and as long as we continue to respect the autonomy of the patient and act in such a way to do no harm then you should be comfortable in your ethics.

Cheers,

- Matt

[fiznat]

1) Did I violate this persons 'right to refuse' by withholding necessary interventions until leaving his home?

2) Despite being in the best interest of my pt, was this an unethical/immoral thing to do?

1. Yes, but ONLY if you did what you did out of the sole purpose of bypassing this patient's right to choose. But you didn't, did you? Of course not. You did what you did so that your patient could get the proper care in a timely fashion as best you know how.

2. This is the same question over again. The only crime you committed here is in over thinking the situation and trying to balance too many "what if" scenarios all at once. These questions about morality and ultimate consequences are for the philosophers, Dwayne. In the meantime, get some sugar in your patient, get him to the hospital, and don't break the law. ...In whichever order you choose.

[aussiephil]

I believe you did the right thing with this patient.

I think that this is not just an immediate health issue, but moreso a whole of health issue. While many 70 year olds are more than capable of living unaided at home, I think in this case questions need to be asked of this patient & maybe supported care is more appropriate to ensure meds are taken, meals provided (substantive meals) etc.

I would also question the possibility of diminished mental faculties (dementia of some sort).

Dwayne, it sounds like you have made a decision based on the patients presenting condition as a medical emergency, you saw a need for hospitalisation & acted appropriatley. Well done.

[codeblue]

Implied consent? You were looking out for the patient and their best interest so I don't see where their would be any discrepency...Were the police on scene?

[Mateo_1387]

Someone mentioned a delay in treatment being unethical. To combat this...

Arrive on scene and complete your initial workup. Once you realize this is a diabetic patient place the patient on the stretcher. Start with some oxygen, start an IV, and begin your slow infusion of Dextrose 50%. This medication needs to be administered slowly, so while moving your patient towards the ambulance keep pushing in a few mL's. This will solve your delay in treatment and get you moving towards the right direction (towards the ambulance).

The only crime you committed here is in over thinking the situation and trying to balance too many "what if" scenarios all at once. These questions about morality and ultimate consequences are for the philosophers, Dwayne. ...

I am hoping you mean that Dwayne should have these 'what if' scenarios thought out before hand and not on the scene, although at times we have to think about a dilemma on the spot. This is just my preference, but I would rather figure out these dilemmas on my own than to rely on someone else's thinking exclusively. I am willing to bet Dwayne feels similarly. He is a bit of an amateur philosopher...