A question of ethics

[Richard B the EMT]

DwayneEMTP: When I have been in that situation, I am not going to lie, but I'm not going to tell the truth either. I'd hedge my bets by telling the patient something to the effect of "Not if I can help it."

[emtgrimreaper]

lying is something that should not be done to a patient. but this is my opinion. everyone sees things differently.

[Mateo_1387]

I hate absolutes, and have in fact found that any time that I try and construct one the EMS Gods swoop down and make me look like a bigger shithead than usual.

Never palm the breast in a 12 lead, never lie...never, never, always, always, yadda, yadda.

I believe it all resolves around your moral and ethical intent.

What revolves around moral and ethical intent? Coercion, lying, or palmin' breast?

Initially upon reading this, I am going to state this. Your moral and ethical intent may not be what the patient wants. Trying to apply my perspective of moral and ethical intents does not necessarily apply to my patient's standards for morals and ethical dilemmas. Is this illogical?

He asked, "goin'........................to............die?" I said, "No worries brother, we're pushing it back. Can't you feel it?" But yeah, there was almost no doubt in my mind that he was going to die before I got him to the hospital. He didn't, thanks in almost no part to me, but what I really didn't want to do was tell the truth, add to his axiety and increase my already shitty position.

So those that believe that lying is 'always' bad...was the better answer then, "Yeah man, I'm afraid you're going to die, I just can't get ahead of this thing.'?

Whatcha think?

How about a reply like this. "Sir, your condition is serious (Admit the truth) but you are doing a great job working with me to help you feel better (offering a positive and encouraging reinforcer).

Or, just ignore the question and offer a ton of positive reinforcement to help keep the patient focused on following your commands to help him breath better.

Just thinking out loud...

Matty

[DwayneEMTP]

What revolves around moral and ethical intent? Coercion, lying, or palmin' breast?

Yes

Initially upon reading this, I am going to state this. Your moral and ethical intent may not be what the patient wants. Trying to apply my perspective of moral and ethical intents does not necessarily apply to my patient's standards for morals and ethical dilemmas. Is this illogical?

Not illogical at all. But as morals and ethics are something that for many of us are complex and confusing concepts, in those unusual moments when decisions have to be made using their application I'll not have time to explore those of my patient. I must use those that I've developed for myself and try to apply them in the best interest of my patient.

How about a reply like this. "Sir, your condition is serious (Admit the truth) but you are doing a great job working with me to help you feel better (offering a positive and encouraging reinforcer).

I believe that in this instance that I've then covered my ass, but haven't advocated for my patient. In my opinion my moral and ethical obligation here is to make him better. I'm willing to bet that had I given the patient in my example this answer I would have caused his bullshit detector to redline. He knew his condition was serious, he knew he was in big trouble, and knowing how big exactly was going to effect his physiological response to treatment in some regards I believe. I could have given a more politically correct answer perhaps, but being politically correct was not my intention, getting him to the hospital alive was.

I don't advocate lying as a general medical tool, but more so was attempting to debunk the idea of 'always' and 'never' as intelligent, useful language when discussing many things EMS related.

Or, just ignore the question and offer a ton of positive reinforcement to help keep the patient focused on following your commands to help him breath better.

Here again I'm not saying that this is a wrong answer in general, just wrong for me in the given situation. I could never ignore such a question and expect my patient to continue to trust me. Also, I believed these to likely be that last moments of his life...I didn't want them to be any more horrifying than they already were. The standard party line says I should have found a way to be honest. The human being in me felt that it was more important to be kind and productive. That was my moral/ethical intent when I lied to him. See? Perhaps this is off in the ditch, I'm not sure, that's why I love these debates.

Just thinking out loud...

And your thoughts are always worth hearing and considering...thanks for sharing them Matty.

Dwayne

[crotchitymedic1986]

Guess you never had a dying patient look you in the eye and ask, "Am I going to die ?" And what's the difference between lying to your boss (I am too sick to work today) or lying in your documentation to cover your butt versus lying to a patient. If you lie you lie.

Edited January 21, 2010 by crotchitymedic1986

[Mateo_1387]

Yes (In reference to intent of palmin' breasts, lying and coercion)

You certainly have a point...but...

Intent looks good, but does not leave always favor outcomes. I am sure volly EMT's claim to have good intents when doing their jobs, but, when they malpractice, they are held responsible, good intent or not.

Not illogical at all. But as morals and ethics are something that for many of us are complex and confusing concepts, in those unusual moments when decisions have to be made using their application I'll not have time to explore those of my patient. I must use those that I've developed for myself and try to apply them in the best interest of my patient.

Interesting answer. I get the impression that if we follow our own morals and ethics then we are following a cowboy model of ethics and morals.

I am assuming, and maybe it is a wrong assumption, that this discussion is about lying to patients to compel them to the hospital. I then redirected it by replying to fireflymedic's post about the use of coercion. To clearly spell it out, what I was saying in my initial reply to your post is that using those tactics to promote your intent is poor form because the patient may not share your idea of what you think is best for them (the patient). This is my perspective.

I believe that in this instance that I've then covered my ass, but haven't advocated for my patient. In my opinion my moral and ethical obligation here is to make him better. I'm willing to bet that had I given the patient in my example this answer I would have caused his bullshit detector to redline. He knew his condition was serious, he knew he was in big trouble, and knowing how big exactly was going to effect his physiological response to treatment in some regards I believe. I could have given a more politically correct answer perhaps, but being politically correct was not my intention, getting him to the hospital alive was.

Why should we lie to dying patient's? Comfort level with the situation maybe? I bet this patient you described already knew he was in serious condition and was close to dying. You answered to him 'no worries brother, we are pushing it back, can't you feel it?'. What was the patient's reply to this? How do you think he took this response. Also, with him saying 'going.....to.....die', are you sure it was a question, or was it a statement?

I don't advocate lying as a general medical tool, but more so was attempting to debunk the idea of 'always' and 'never' as intelligent, useful language when discussing many things EMS related.

I get that. Finding exceptions to rules are fun.

Here again I'm not saying that this is a wrong answer in general, just wrong for me in the given situation. I could never ignore such a question and expect my patient to continue to trust me. Also, I believed these to likely be that last moments of his life...I didn't want them to be any more horrifying than they already were. The standard party line says I should have found a way to be honest. The human being in me felt that it was more important to be kind and productive. That was my moral/ethical intent when I lied to him. See? Perhaps this is off in the ditch, I'm not sure, that's why I love these debates.

I like these debates too.

Your lie may have had the best of intentions, yet he could very well have saw right through them. I probably would not ignore the question either. Honestly, I think if you patient was that sick, trust would not be the biggest deal in the world to him, survival would. I know this probably sounds like practicing psychology, but telling him the truth may better prepare him for death than giving false hopes of life. At the same time, giving him motivation to beat what could be imminent (death) is not the same as false hope.

Guess you never had a dying patient look you in the eye and ask, "Am I going to die ?" And what's the difference between lying to your boss (I am too sick to work today) or lying in your documentation to cover your butt versus lying to a patient. If you lie you lie.

What point you making about never having a dying patient ask 'Am I going to die?"

Sure, the components of a lie are the same, the effect it has varies though. Lying to your boss about being sick versus lying to your wife about where you were last night can have totally different effects.

I will be sure to give this topic some more thought and maybe can come back with something ever better.

Y'all have a good one.

Matty.

[scubanurse]

Lying to patients isn't always wrong. There are some native american tribes who hold the believe that the person who is dying can not know that they are in fact dying. They believe that this would cause the patient to give up hope and therefore stop fighting and die.

When it comes to the topic of what is ethically and morally "correct" for a situation, there is no right or wrong answer. Multiple factors come into play, such as their religious and cultural beliefs, their emotional maturity to handle a bad situation, and other beliefs the patient and their family may hold. It is not the providers opinion that matters in cases like these, it is what the patients belief is.

Under the ethical principle of beneficence and nonmaleficence, in a case like the OP presented, lying to the patient to get them to go to the hospital, would not be bad. As both your motivation for lying to the patient and the outcome of getting the patient to the hospital to receive proper treatment would be good, you're covered under both utilitarianism and deotonlogy, the two big ethical theories when it comes to medical ethics.

But then again, Kant did argue that it is wrong to lie regardless of the consequences.

This is why I love ethics so much!!

My personal view point is that if it is to prevent harm to the patient and to benefit the patients health then it is okay to lie.

Edited January 23, 2010 by scoobykate

[thrutheashes]

Hey guys,

Thank you all for the great posts in regards to this topic. It definitely gives some food for thought.

Thrutheashes

[Lone Star]

*DISCLAIMER: The thoughts expressed here are MY thoughts! By no means am I trying to dictate, browbeat or harangue anyone into seeing things from my perspective!

Do I advocate lying to a patient? No.

Do I tell a dying patient that they're going to die? No.

Do I lie to a patient (or 'stretch the truth') to get them to go to the hospital? No.

Lying to your patient is a sure fire way to lose any trust and rapport that you have worked on establishing since you got on scene.

In the case of the critical patient who asks if they're going to die, I would inform them that they're in pretty rough shape, but would further tell them that I'm going to do everything in my power to help them.

Have I lied to them? No.

Did I instill false hope? No.

Does this make me a 'bad practitioner'? No.

In the above situation (which actually happened to me), I explained that the situation was 'grim' at best, but reassured them that I was going to do everything possible to help them. I didn't ignore the question, I didn't downplay their concerns and I didn't lie to them.

To me 'lying by omission' is the same thing as flat out lying to them. There is no 'happy medium' about it. Lying to your patient (by whatever means you've chosen), is still lying to your patient. It destroys the confidence and trust that they have placed in you to help them. They WILL see through it!

Patient: I don't think this cut is serious enough to have to go to the hospital.

EMT-(insert license level here): If you don't get that laceration treated, it'll get infected, and that will lead to gangrene and they'll have to cut it off!

I would explain to the patient that there is a POSSIBILITY that the wound could become infected, and that it would lead to further complications that COULD end up putting them in the hospital for longer than it would take to have it looked at in the ER.

Ultimately, as long as the patient is competent to make their own decisions, then I have no choice but to let them RMA. Even then, there's a boatload of documentation that I'll file to note that I DID try to get them to seek medical attention above what I am able to provide. In the event that the patient is NOT competent enough to make their own decisions, I'm going to use the family, friends and what other means are available to me to get that patient to more definative care than I may be able to provide.

[DwayneEMTP]

You certainly have a point...but...

Intent looks good, but does not leave always favor outcomes. I am sure volly EMT's claim to have good intents when doing their jobs, but, when they malpractice, they are held responsible, good intent or not.

Most of our societal laws revolve around intent. Does my belief that at times I may lie secondary to my intent to be my patient's advocate make me right? Heh...not by a long shot. But when you're as dense as I am there are many times that situations were not covered in class, nor by previous experience, so I then have to do what I believe I'll be able to live with tomorrow. Bad answer I know, but it seems that very often, in my most critical patients, that I don't always have all that I need in my 'good answer toolbox.' :-)

Interesting answer. I get the impression that if we follow our own morals and ethics then we are following a cowboy model of ethics and morals.

It wasn't necessarily my moral ethic. It was that of EMS, in that I believe that becoming a medic bound me morally and ethically to do all within my power to care for those that are put into my hands. I gained nothing personally by this lie. I believed that his anxiety was helping to retard his condition and gave an answer that I believed would a) perhaps help him relax and therefore respond better to treatment, or at least not make him worse.

In fact, I'll take it one step further. What I really wanted to do was to hit this guy with about 8mg of Valium to calm him down, out of kindness, but also in the hopes of making him more compliant to me managing his respirations, but my protocols don't specifically allow for this use, nor is it listed as an option for DOB. (If you remember, or maybe I didn't state it, he'd made it clear that he didn't want a tube if at all possible.) So I chose to allow him to suffer more than was necessary. By following my protocols I may be shown to be ethically sound, but I would say morally bankrupt as I allowed my pt to suffer in order to cover my ass. I ran this scenario by my medical director the next day and he was in fact disappointed in my decison as I have a guideline that allows for chemical restraint of combative patients, or those suffering from severe anxiety. But I pictued myself in front of a jury being asked, by a whole room of non medical people, "So you gave a person that was soffocating a drug that's known to hinder their respriatory drive?? What kind of bullshit is that!?!?" I was such a pussy.

We have very liberal protocols, with almost nothing spelled out as a certainty. Lots of 'might' or 'may' or 'should' language. But I followed my protocols, so does this make me morally and ethically sound? Or would doing what I was certain was right despite being a 'cowboy' perhaps have been the better choice?

That is the first time that I can remember that I made a medical decision based on what I believed others might think, and I sure as hell hope it's the last.

I am assuming, and maybe it is a wrong assumption, that this discussion is about lying to patients to compel them to the hospital. I then redirected it by replying to fireflymedic's post about the use of coercion. To clearly spell it out, what I was saying in my initial reply to your post is that using those tactics to promote your intent is poor form because the patient may not share your idea of what you think is best for them (the patient). This is my perspective.

And I agree. Though sometimes I want to simply beat patients onto my cot for their own good, I'm a true blue believer in a patient's right to decide their own fate if able.

Why should we lie to dying patient's? Comfort level with the situation maybe? I bet this patient you described already knew he was in serious condition and was close to dying. You answered to him 'no worries brother, we are pushing it back, can't you feel it?'. What was the patient's reply to this? How do you think he took this response.

I believe that he took it at face value. He did seem to relax a bit and breath a little bit easier when he believed we were winning instead of losing. (Really? Or did I simply see what I'd hoped to see? Not sure.)

Also, with him saying 'going.....to.....die', are you sure it was a question, or was it a statement?

I'm confident that it was a question, though could certainly be wrong.

I get that. Finding exceptions to rules are fun.

I'd say that finding the exceptions, at times, is my obligation if the rule is bullshit, or simply to far off of the mark to be useful.

Honestly, I think if you patient was that sick, trust would not be the biggest deal in the world to him, survival would.

I disagree completely here. In moments of severe terror I need to know that the person caring for me is ONLY caring for me, not playing word games. As soon as I would have heard a politically correct answer where a straight forward answer was expected I would lose faith and that would add to my terror and in this case likely degrade my already hinky status.

I know this probably sounds like practicing psychology, but telling him the truth may better prepare him for death than giving false hopes of life. At the same time, giving him motivation to beat what could be imminent (death) is not the same as false hope.

In this case if he died he'll remember nothing, and if he lives will remember that I was right. Seems win/win. Now, I was discussing this with Wendy and she made a great point that this might have been ok while we're alone in the ambulance, but certainly wrong if there were family or friends present, to which I wholy agree.

I will be sure to give this topic some more thought and maybe can come back with something ever better.

I'm counting on it.

Thanks for your thoughts Matty.

On a different topic. LoneStar your posts, both the quality of thought and the presentation have increased dramatically in the last year!! Good to see brother. I don't have time to respond to your post line by line right now, but it was certainly worth reading. Thanks for taking the time to post.

Dwayne