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

[Mateo_1387]

Will I next choose to work the viable looking 50 year old with a DNR because I believe I know better than they do? No, I will not. But what is the difference between these two patients? Why is one decision good for one, but not the other? It seems right, I just can't define why it IS right. See?

Do you feel the same way about narcotic overdose patients?

It took me reading this twice to figure out what was about to cause you to vapor lock, but I figured it out. How can both patients have certain wishes, but only one really gets a choice in the matter, that of course being the DNR patient.

Again, the way I am seeing it...

Have you ever been to the home of a diabetic where it was written on paper, signed by a medial professional, and notarized that the diabetic patient did not want treatment or transport during the event of hypoglycemia? I am sure the family told you the patient's wishes, but can you really defend yourself with just their word? I honestly do not think so. I think in that situation we are forced to act on the best interest of the patient under the assumption that under normal circumstances, he would not refuse the care.

[DwayneEMTP]

Do you feel the same way about narcotic overdose patients?

Man. Good question. Do I question their right to refuse treatment? No, not so much as I have the right secondary to implied consent. I've never known the wishes of an overdose, but if I did, without the direction of an attending physician, would not feel comfortable following them based on the fact that the overdose seems to signify an inability to maintain the reliable mentation necessary for such a decision.

took me reading this twice to figure out what was about to cause you to vapor lock, but I figured it out. How can both patients have certain wishes, but only one really gets a choice in the matter, that of course being the DNR patient.

Exactly.

, the way I am seeing it...

Have you ever been to the home of a diabetic where it was written on paper, signed by a medial professional, and notarized that the diabetic patient did not want treatment or transport during the event of hypoglycemia?

No, but I once chose not to work an arrest that happened in front of me based on the patient's, reinforced by the family, wishes that he did not wish to be resuscitated. No DNR on scene, or even issued in fact.

I am sure the family told you the patient's wishes, but can you really defend yourself with just their word? I honestly do not think so. I think in that situation we are forced to act on the best interest of the patient under the assumption that under normal circumstances, he would not refuse the care.

But see, this is where I seem to be a freak, in that I have less desire to defend myself than to I do to make the 'right' decision. In the arrest I mention above, I really had little defense had the family changed their stories afterward. I did make sure I had police witnesses to all statements but did not get them in writing. I couldn't tolerate the thought of removing his last opportunity to exercise his personal power. This PCR was called to the attention of my medical director, by me, who suggested I do more to protect myself in the future but had no issues with the decision.

I actually see these issues at the heart of paramedic medicine. I have only very rarely been at a loss for the appropriate medicine to use at a certain moment, but find that I am regularly challenged to decide the 'right' and 'wrong' from a moral/ethical point of view.

Thanks for your reply Matty. I look forward to your thoughts.

Fiz, Coz, aren't these issues right down your alleys? :-)

Dwayne

[cosgrojo]

Fiz, Coz, aren't these issues right down your alleys? :-)

Dwayne

Why yes they are Dwayne... thanks for thinking of me...

I myself have had the internal debates that are at times paralysing your ability to decide. In truth, they are issues that often go unresolved in my own mind. Currently (and I reserve the right to change my mind), I believe that trying to come to some sort of moral consensus is not something that will make you a better provider... just a more confused one. It is cliche, but one cannot compare apples to oranges. So while we torture ourselves because of the similarities between the Diabetic vs. Narcotic OD or the Diabetic vs. DNR, we are not accepting that they are situationally different.

I think that it may be easier for you to accept your decisions if you realize that we need to treat every situation different. And while some situations may only differ by a micron or two... it is still different and may require a different decision. This is the greatest failure of the "protocol" system. Protocols do not do a good enough job of defining the duties and responsibilities of an EMS provider. This is why the best providers use them as guidelines as opposed to strict protocols.

What I think may be happening to you Dwayne, is that you are trying to assign some sort of "Moral Protocol" to your treatment paradigm. This will never work for you because morals are not set in stone, they are fluid. Think of how much your personal morals have changed since you were a child, then young adult, then full fledged responsible adult. They have changed a lot, and so have everyone else's. Trying to make everything fit into one moral template will only lead to frustration.

While my previous three paragraphs are chock full of wise generalizations... they often don't help when you are on the call. We are either devoid of appropriate information, or sometimes have that information being intentionally withheld from us, making it very difficult to make these decisions. We are all only able to do our best out there. Sometimes it is a swing and a miss, other times we hit a homer. When the call is over, we have to know we did our best... and acted as best we could under the circumstances. I wish I could tie it all into a nice neat bow... but a philosopher understands that there are no such things as an easy answer.

[fiznat]

Dwayne,

The crux of the issue for me is your answer to this question:

Did you delay this patient's treatment for the sole purpose of avoiding a refusal?

[DwayneEMTP]

Dwayne,

The crux of the issue for me is your answer to this question:

Did you delay this patient's treatment for the sole purpose of avoiding a refusal?

Yeah, I guess I did. I had a reliable history that told me that I was likely dealing soley with a hypoglycemic emergency. Which follows, in my mind, that I could have temporarily corrected that issues and returned him to his normal mentation, and then left him, per his predicted wishes.

So I don't believe that my decision to withhold the sugar until it was unrealistic for him to refuse was a benefit to his medical treatment. But I do believe that 'forcing' him to a place where he would recieve what I believed to be the more appropriate medical treatement, as well as the possibility for ongoing care, was best for him.'

So ultimately I forced him to recieve medical treatment that I believed he would have refused if able. Now, in hindsight it turns out I was mistaken. He was grateful for the treatment he recieved from me and for the opportunity to more fully resolve the issues he'd been suffering.

Now, I'm comfortable that my treatment was strictly patient advocacy based, but do we have the right to advocate for patients against their properly mentating wishes? Or to withhold the opportunity to properly mentate, when it's within our power to give it, so that we can gift them with our advocacy? (Yikes, sounds terribly arrogant when put that way, doesn't it?)

I'm no longer crunching this issue from a conscience point of view, but still certainly find it interesting from a philisophical point of view.

Thanks to all for your responses!

Dwayne

[fiznat]

I do believe that 'forcing' him to a place where he would recieve what I believed to be the more appropriate medical treatement, as well as the possibility for ongoing care, was best for him.

So for the purpose of argument, we may stipulate:

1. You thought that the patient was suffering from a hypoglycemic episode.

2. You knew this condition was treatable by you "inside the home" (as rapidly as possible).

3. You thought that if treated, the patient would return to his baseline mental status and refuse further care.

4. You chose to delay treatment for the express purpose of avoiding a refusal (not for any other medical reason).

If all of these are true, I'm going to say that you did the wrong thing. To delay treatment for the express purpose of avoiding a transport refusal is akin to forcing this patient, against his will, to the hospital. Since we may assume that you knew what this patient's choice was going to be, we can argue that you took action specifically to undermine that choice. You say you did this because it was "best" for the patient, but this is not a decision that we are allowed to make. Carrying your logic to it's conclusion, would you also argue that we should be able to force conscious people to the hospital as well, if we believe that such action would be subjectively "better" for them also?

Our right to make decisions for altered patients ("implied consent") is based in the assumption that if this patient were of sound mind, he/she, as a reasonable person, would make the choice to be treated. This doesn't translate to the patient in question. Your choice to delay treatment was in effort to undermine a choice that would come from this patient's sound and coherent mind - NOT from an altered or confused state. You undermined a conscious and coherent decision. That is not implied consent.

Furthermore, you may have done harm (or at least created the potential for harm) to this patient through your actions. You chose to lengthen the time this patient was hypoglycemic, which increases the chances of injury. What if this patient had a seizure during the interim, or if - since he couldn't walk - you dropped him carrying out to the ambulance? How would you defend your decisions then?

There is a fine line between advocating for your patient and trampling on their right to choose. I think, in this case, you crossed that line.

(no hard feelings Dwayne. You wanted a discussion, you got one haha )

Edited September 20, 2009 by fiznat

[HERBIE1]

So for the purpose of argument, we may stipulate:

1. You thought that the patient was suffering from a hypoglycemic episode.

2. You knew this condition was treatable by you "inside the home" (as rapidly as possible).

3. You thought that if treated, the patient would return to his baseline mental status and refuse further care.

4. You chose to delay treatment for the express purpose of avoiding a refusal (not for any other medical reason).

If all of these are true, I'm going to say that you did the wrong thing. To delay treatment for the express purpose of avoiding a transport refusal is akin to forcing this patient, against his will, to the hospital. Since we may assume that you knew what this patient's choice was going to be, we can argue that you took action specifically to undermine that choice. You say you did this because it was "best" for the patient, but this is not a decision that we are allowed to make. Carrying your logic to it's conclusion, would you also argue that we should be able to force conscious people to the hospital as well, if we believe that such action would be subjectively "better" for them also?

Our right to make decisions for altered patients ("implied consent") is based in the assumption that if this patient were of sound mind, he/she, as a reasonable person, would make the choice to be treated. This doesn't translate to the patient in question. Your choice to delay treatment was in effort to undermine a choice that would come from this patient's sound and coherent mind - NOT from an altered or confused state. You undermined a conscious and coherent decision. That is not implied consent.

Furthermore, you may have done harm (or at least created the potential for harm) to this patient through your actions. You chose to lengthen the time this patient was hypoglycemic, which increases the chances of injury. What if this patient had a seizure during the interim, or if - since he couldn't walk - you dropped him carrying out to the ambulance? How would you defend your decisions then?

There is a fine line between advocating for your patient and trampling on their right to choose. I think, in this case, you crossed that line.

(no hard feelings Dwayne. You wanted a discussion, you got one haha )

It doesn't matter what the patient's mental status becomes AFTER treatment, it's what you see when you arrive, so like all patients, you assume they want to be treated as well as transported. Even on diabetics, I never look at them as a potential refusal, even though it may be quite likely. If they are unresponsive/incompetent when you arrive, you do what's in the best interests of the patient. You cannot presume to KNOW what they will want later. I've had patients surprise me AND their family who SWEAR the person will refuse when we wake them up and they decide to go to the ER. Yes, their glucose level may be back to normal, but who knows how they will feel after they wake up? Will they wake up with chest pain, abdominal pain, or some other complaint? Yes, multiple incidents with the same patient in the same situation and chances are you are right on target with your assumptions, but there are no guarantees.

Part of the reason we allow patients to refuse is that they have a support system, and will comply with your instructions.

In the case of a patient in poor living conditions and poor support, there is a good chance they will not or cannot comply with your directions. Is it wrong then to transport them to a place that may be able to get them the social services they need to be able to take proper care of themselves? Treating the medical part is easy- getting them the social service assistance is far more difficult- even in the hospital. Ensuring they receive those services at home is even harder. Getting them to accept that help may be another issue too, but you do the best you can.

I see nothing unethical in what Dwayne did. In fact, I see the opposite- he went the extra mile for his patient.

[Eydawn]

Dwayne hasn't let this really percolate enough. Here's my analysis of this: The problem you were called for is just a symptom of the real problem.

Someone who's had multiple diabetic exacerbations within a short time frame is suffering from an acute diabetic crisis, not just an isolated episode of hypoglycemia. While we often track ourselves into thinking only about the short term problem, we do treatments that affect long term care.

Dwayne's brain jumped from looking at the short term problem to seeing the bigger picture problem, and chose the appropriate treatment for the actual problem.

The way I see it: He treated the symptom. He didn't fail to treat. You *have* to treat what you see... your time frame may vary depending on the situation. For example, the climber who falls is going to get morphine/fentanyl for the pain of his tib/fib fracture... but is it more prudent to dangle your paramedic on a rope with an IV setup, or is it better to wait until the patient is on the ground and stabilized? Is it more appropriate to treat hypoglycemia right this second and bypass the issue of addressing this diabetic crisis, or is it more appropriate to ensure that the person receives the care they *really* need?

It wasn't that Dwayne wanted to pull a power play and take away the person's choice... he just wanted to give the person the chance to accept care or refuse it in the presence of an actual doctor, where the actual problem stood a chance of being addressed. Someone really doesn't want care, they'll refuse it just as well in a hospital as they will in the back of your ambulance or in their living room. It's not like Dwayne left the guy completely zonked so that the hospital staff could also operate under implied consent... he just started treating en-route to change the venue of potential refusal. Which to me ensures the best possible outcome: It gives the patient a chance to refuse, while upping the odds that the problem will be fixed.

Refusing this guy in his home would have led to several more calls and probably permanent damage to the patient's system. Doesn't take long for diabetics like that to spiral downhill and crash hard.

Just my thoughts...

Wendy

CO EMT-B

[DwayneEMTP]

Fiz, your assumptions are all correct. And of course there are no hard feelings, your honesty and intelligence is what makes you such an asset here!

Your point is taken in the spirit intended, but should I have chosen to act differently, and in fact generated a refusal, given this patients history, what then if he becomes worse, strokes or seizes not long after I'm gone?

Is that just an 'oh shit' moment? Or is there moral liability there for the provider?

Chatting with Wendy made me think...

This may be akin to pulling the sober, though homeless man into your ambulance so that he can warm up and then turning him back out into the snow and expecting him to stay warm from now on.

Do you have an obligation to to attempt to coerce, cajole, trick him into going somewhere warmer if you believe that releasing him brings the likelihood of life ending hypothermia?

I don't know if I should, I just know that I would...but there's the rub..

Dwayne

[tniuqs]

I chose to remove this pt's ability to refuse, (or did I?)

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?

Dwayne

"Implied consent is a form of consent which is not expressly granted by a person, but rather inferred from a person's actions and the facts and circumstances of a particular situation (or in some cases, by a person's silence or inaction)"

Honestly I don't see why your beating yourself up with this situation and where you chose to treat this patient is of little consequence unless after treatment and a GCS of 15 then you continued to transport against his wishes.

IMHO you did the right thing.

So my conundrum would be ... is it wrong when treating a "lady of the evening" bartering to receive a discount for bring your own bed ?

cheers

Edited September 21, 2009 by tniuqs