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

[fiznat]

I am hoping you mean...

I guess what I mean is that the question Dwayne is asking is a complex one without an easy answer. I think it would make an excellent philosophical debate on the moral issues, one that would probably have entrenched opponents for each side, both with excellent and well founded points to consider. I have a degree in philosophy and these are the types of scenarios my fellow students loved to sit and discuss for hours on end.

Still, I don't think that is what Dwayne is looking for. The practical answer, I think, is the one that I originally stated: that Dwayne did the right thing because he provided the highest level of care possible for his patient, in a timely fashion and without breaking the law. We can discuss the philosophy all night if you prefer, but I think for us, this is probably what it boils down to.

[Mateo_1387]

I guess what I mean is that the question Dwayne is asking is a complex one without an easy answer. I think it would make an excellent philosophical debate on the moral issues, one that would probably have entrenched opponents for each side, both with excellent and well founded points to consider. I have a degree in philosophy and these are the types of scenarios my fellow students loved to sit and discuss for hours on end.

Sounds like fun. I am betting there is an answer. It would certainly make us stronger to truly be able to debate the finer points of the moral issue.

Still, I don't think that is what Dwayne is looking for. The practical answer, I think, is the one that I originally stated: that Dwayne did the right thing because he provided the highest level of care possible for his patient, in a timely fashion and without breaking the law. We can discuss the philosophy all night if you prefer, but I think for us, this is probably what it boils down to.

Then again, maybe it is what he is looking for. I hope he comes back and tell us. Personally, I do not think Dwayne needs to hear 'good job' but rather wants to internally be satisfied with his decisions. I do agree that he 'did the right thing because he provided the highest level of care possible for his patient, in a timely fashion and without breaking the law.'

Fiz, thanks for taking the time to reply.

Matty

[paramedicmike]

Dwayne,

Not only would I have taken the same actions as you did with this particular patient, I have done this very same thing in the past. I do not believe it violates a patient's right to refuse. You acted in the best interest of the patient taking into account extraneous factors that affect this patient outside of his medical condition and presentation to you.

Nice job.

-be safe

[Lone Star]

From what I can see about the whole situation, it could be justified that based on patient's condition, there was no time to 'stay and play' on scene. This means that some of our treatments will be done enroute.

Does this violate the patient's right to refuse treatment? I'd have to say, no. Working on the patient with implied consent, the decision to 'load and go' was essential to getting the patient to definitive care (which he desperately needed).

In EMS, we have to be an advocate for our patient, and sometimes this means that we have to do things like this. Obviously the patient's condition demanded more aggressive treatment than we normally give in the field.

Granted, Dwayne could have 'fixed him right up'; at least temporarily...but that's only a 'band-aid solution' to the underlying problem.

[cosgrojo]

I contend that any attempt to "stay & play," with the desire to sign someone off, is a violation of your duty to the patient. If you encounter a patient that has some form of altered mentation level (especially ones that lead to airway compromise!), I believe you are obligated to transport them no matter what condition you improve them to. There are just so many things that can be wrong with them, and so many co-morbidities that the patient probably has, that it would be irresponsible to sign them off.

More than the decision to transport against the will of the family, and sticking up for what you believe to be appropriate... I liked the part of the story where another co-worker called you to give you a heads-up about this patient. That is the type of information that is usually missing from our assessments that can make all the difference in the world. I have always appreciated it when people have done that for me in the past. Not only was it nice for your co-worker to do that, but it played a role in the decision to transport. It is rare that we get to peel more than a couple of layers off of the onion.

[Happiness]

I cant believe that you Dwayne are even douting your actions. BAD BAD BAD. You are one of the people that come here and post and you actually make sense when doing so until now. So you are questioning your ethical and moral professionalizm (if you correct any of my spelling you will have happiness comming through your computer screen) on an elderly man with a history of refusing transport and YOU found a way around it. This elderly man now has the opportunity to get the proper assement. You my dear man have the ability to look outside of the box and did so on this call. So the other question did you really delay any treatment, yes I know diabetic calls are stay and play calls in general but when your dealing with the elderly the fact that they can crash at any momment makes it a load and go and thats what you did.

Well anywho dont dout yourself MR. Dwayne

[akflightmedic]

He is a bit of an amateur...

Fixed it for ya...

[HERBIE1]

Here's a wrinkle nobody has brought up. Again- I commend Dwayne on his decision, but...

To answer his question about the ethical/moral dilemma of treating enroute, what about a trauma patient?

We have had the "golden hour" concept drilled into our heads with the intent that the less time spent onscene, the better the outcome for the patient. Anything you can do enroute, you do. Obviously a seriously injured trauma patient will not be "fixed" by anyone but a surgeon and an OR.

My point is, time, place, and APPROPRIATE care. In the case of a trauma patient, definitive care is NOT with us, but a simple hypoglycemic diabetic with no complicating factors really only needs to have their glucose level increased. In this case, the man needed more care, but it was more of a social service intervention than a medical one. If you could ensure that he would get the needed resources and agencies involved with his care without transporting him, then he would be getting his "definitive" care. Problem is, we all know how slowly the wheels of government agencies turn, and there are no guarantees that help would get there in time for him.

All this shows to me is that as EMS providers, often times we need to think outside the box. We improvise, adapt, and try to do what's best for the patients but many times these situations are not written in an SOP or policy book.

THAT to me is what makes this job fun- problem solving and playing detective. Nearly anyone can master the skills and procedures we perform, but not everyone can adapt those skills or hunt for a "better" solution to a problem.

[11BVet]

One of the other local services in the area have it in their protocols that state that they can't start D50 until enroute to ED to eliminate the "I feel better now, thanks but I'm not going." Not saying right or wrong, but it seems to be fine with their medical director.

[DwayneEMTP]

Holy smokes all...this is awesome! I truly expected that this thread was going to be ignored.

Both Fiz and Matty are correct. I have on occasion done things I felt were in the best interest of my patients but believed would get me a beating later, and have had no real issue with it. This was different from the point of view that I truly believe people have the right to be the pilot of their destiny up to, and including deciding to die.

I'm thrilled that so many of the people I respect here were kind enough to voice an opinion, though I truly believed that many of those opinions were going to be negative.

I just couldn't find a good place in my head for this for some reason.

Did I do what's best for my patient? I believe I did.

Does he have the right, when mentating properly, to choose to do things NOT in his best interest? I believe he does.

Did I believe I knew his wishes when I chose not to attempt to restore his mentation before transport? I believed so.

Do I have the right to make that choice for him when I believe he might cuss me for it later? For some reason I believed I did.

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?

See what happened? I nearly ended up in vapor lock.

This patient in fact did not cuss me when he awoke. He realized that something was out of control, that it was threatening his life, and wanted to get it resolved. Whew.

Thank you all for your time, and your kind and honest answers. I am with Matty though. I'd like to figure out what makes it right, or wrong, and where the lines are drawn. Right now I feel like the judge that said something to the effect, "I don't need to define pornography! I know it when I see it!" I didn't like his answer, and though I feel good about my decision, don't like my answer either.

Dwayne