Hostname: page-component-78c5997874-94fs2 Total loading time: 0 Render date: 2024-11-10T07:31:03.526Z Has data issue: false hasContentIssue false
  • English
  • Français

The Ethics of Real-Time EMS Direction: Suggested Curricular Content

Published online by Cambridge University Press:  14 February 2018

Jay M. Brenner ,
Andrew L. Aswegan ,
Laura E. Vearrier ,
Jesse B. Basford  and
Kenneth V. Iserson
Jay M. Brenner*
Affiliation:
Department of Emergency Medicine, SUNY-Upstate Medical University, Syracuse, New York USA
Andrew L. Aswegan
Affiliation:
Department of Emergency Medicine, Union Hospital, Elkton, Maryland USA
Laura E. Vearrier
Affiliation:
Department of Emergency Medicine, Drexel University, Philadelphia, Pennsylvania USA
Jesse B. Basford
Affiliation:
Department of Emergency Medicine, Louisiana State University, Shreveport, Louisiana USA
Kenneth V. Iserson
Affiliation:
Department of Emergency Medicine, University of Arizona, Tucson, Arizona USA
*
Correspondence: Jay M. Brenner, MD Department of Emergency Medicine SUNY-Upstate Medical University Syracuse, New York USA E-mail: brennerj@upstate.edu
Get access Rights & Permissions [Opens in a new window]

Abstract

Ethical dilemmas can create moral distress in even the most experienced emergency physicians (EPs). Following reasonable and justified approaches can help alleviate such distress. The purpose of this article is to guide EPs providing Emergency Medical Services (EMS) direction to navigate through common ethical issues confronted in the prehospital delivery of care, including protecting privacy and confidentiality, decision-making capacity and refusal of treatment, withholding of treatment, and termination of resuscitation (TOR). This requires a strong foundation in the principles and theories underlying sound ethical decisions that EPs and prehospital providers make every day in good faith, but will now also make with more awareness and conscientiousness.

BrennerJM, AsweganAL, VearrierLE, BasfordJB, IsersonKV. The Ethics of Real-Time EMS Direction: Suggested Curricular Content. Prehosp Disaster Med. 2018;33(2):201–212.

Keywords

DNREMSethicsmedical directionrefusal of treatment
Type
Special Reports
Information
Prehospital and Disaster Medicine , Volume 33 , Issue 2 , April 2018 , pp. 201 - 212
Copyright
© World Association for Disaster and Emergency Medicine 2018 

Access options

Get access to the full version of this content by using one of the access options below. (Log in options will check for institutional or personal access. Content may require purchase if you do not have access.)

Footnotes

Conflicts of interest: none

References

1. Lu, DW, Adams, JG. Ethical Challenges. In: Cone DC, Brice JH, Delbridge TR, Myers JB (eds). Emergency Medical Services: Clinical Practice and Systems Oversight, Second Edition. West Sussex: Wiley; 2015.Google Scholar
2. Adams, JG, Arnold, R, Siminoff, L, Wolfson, AB. Ethical conflicts in the prehospital setting. Ann Emerg Med. 1992;21(10):1259-1265.CrossRefGoogle ScholarPubMed
3. Heilicser, B, Stocking, C, Siegler, M. Ethical dilemmas in Emergency Medical Services: the perspective of the emergency medical technician. Ann Emerg Med. 1996;27(2):239-243.CrossRefGoogle ScholarPubMed
4. Ethical challenges in Emergency Medical Services: a special contribution of the Ethics Committee, National Association of Emergency Medical Services Physicians. Prehosp Disaster Med. 1993;8(2):179-182.CrossRefGoogle Scholar
5. Larkin, GL, Fowler, RL. Essential ethics for EMS: cardinal virtues and core principles. Emerg Med Clin N Am. 2002;20(4):887-911.CrossRefGoogle ScholarPubMed
6. Becker, TK, Gausche-Hill, M, Aswegan, AL, et al. Ethical challenges in Emergency Medical Services: controversies and recommendations. Prehosp Disaster Med. 2013;28(5):488-497.CrossRefGoogle ScholarPubMed
7. Klugman, CM. Why EMS needs its own ethics. What’s good for other areas of healthcare may not be good for you. EMS Mag. 2007;36(10):114-122.Google Scholar
8. Rao, GVR, Jena, B. “Ethical Issues in Emergency Medical Services (EMS) - Experience from India’s Integrated EMS System.” www.researchgate.net/. Accessed March 2, 2017.Google Scholar
9. Erbay, H. Some ethical issues in prehospital emergency medicine. Turk J Emerg Med. 2014;14(4):193-198.CrossRefGoogle ScholarPubMed
10. Steiner, TH, Sonntag, H-G, Bokonjić, D (eds). Manual of Teaching and Learning in Medicine. www.bhmed-emanual.org/. Accessed November 25, 2016.Google Scholar
11. Iserson, KV, Sanders, AB, Mathieu, DR (eds). Ethics in Emergency Medicine, 2nd edition. Tucson, Arizona USA: Galen Press, Ltd.; 1995.Google Scholar
12. Iserson, KV, Heine, C. Bioethics. In: Marx JA, Hockberger RS, Walls RM (eds). Rosen’s Emergency Medicine: Concepts and Clinical Practice, Eighth Edition. Philadelphia, Pennsylvania USA: Mosby; [In Press] 2017.Google Scholar
13. Iserson, KV, Heine, C. Ethics in Wilderness Medicine. In: Auerbach P. Wilderness Medicine, 7th ed. Amsterdam, Netherlands: Elsevier; 2017: 2262-2271.Google Scholar
14. Iserson, KV. Bioethical Principles. In: Marco C, Schears R (eds). Ethical Dilemmas in Emergency Medicine. New York USA: Cambridge University Press; 2015: 1-17.Google Scholar
15. Beauchamp, T, Childress, J. Principles of Biomedical Ethics. 7th Ed. New York USA: Oxford University Press; 2013.Google Scholar
16. Schmidt, TA, Olszewski, EA, Zive, D, Fromme, EK, Tolle, SW. The Oregon physician orders for life-sustaining treatment registry: a preliminary study of Emergency Medical Services utilization. J Emergency Medicine. 2013;44(4):796-805.CrossRefGoogle ScholarPubMed
17. Iserson, KV. A simplified prehospital advance directive law: Arizona’s approach. Ann Emerg Med. 1993;22(11):1703-1710.CrossRefGoogle ScholarPubMed
18. Iserson, KV. Improvised Medicine: Providing Care in Extreme Environments, 2nd ed. New York, New York USA: McGraw-Hill Publishing; 2016.Google Scholar
19. Moskop, JC, Marco, CA, Larkin, GL, Geiderman, JM, Derse, AR. From Hippocrates to HIPAA: privacy and confidentiality in emergency medicine—part I: conceptual, moral, and legal foundations. Ann Emerg Med. 2005;45(1):53-59.CrossRefGoogle ScholarPubMed
20. Department of Health and Human Services. Standards for Privacy of Individually Identifiable Health Information. Federal Register. 2000;65(250):82464-82829.Google Scholar
21. 45 CFR 164.512. Uses and disclosures for which an authorization or opportunity to agree or object is not required. 45 CFR 164.512. Web: US Government Publishing Office; 2015.Google Scholar
22. Jensen, AM. Protecting patient privacy in community paramedic programs. Amid HIPAA and other rules, how should you approach the need to share protected health information? EMS World. 2016;45(3):48-51.Google ScholarPubMed
23. Conroy, C, Tominaga, GT, Erwin, S, et al. The influence of vehicle damage on injury severity of drivers in head-on motor vehicle crashes. Accid Anal Prev. 2008;40(4):1589-1594.CrossRefGoogle ScholarPubMed
24. Cleveland, N, Colwell, C, Douglass, E, Hopkins, E, Haukoos, JS. Motor vehicle crash severity estimations by physicians and prehospital personnel. Prehosp Emerg Care. 2014;18(3):402-407.CrossRefGoogle ScholarPubMed
25. Medicine PsCftSoEPi, Biomedical, Behavioral Research. Making health care decisions: a report on the ethical and legal implications of informed consent in the patient-practitioner relationship. President’s Commission for the Study of Ethical Problems in Medicine and Biomedical and Behavioral Research. 1982.Google Scholar
26. Conover, K. Against medical advice, 302s, and a medical restraint. Emergency Medicine Grand Rounds. 2009.Google Scholar
27. Appelbaum, PS. Assessment of patients’ competence to consent to treatment. N Engl J Med. 2007;357(18):1834-1840.CrossRefGoogle ScholarPubMed
28. Schmidt, T, Neely, KW, Adams, AL, et al. Is it possible to safely triage callers to EMS dispatch centers to alternative resources? Prehosp Emerg Care. 2003;7(3):368-374.CrossRefGoogle ScholarPubMed
29. Corbett, SW, Grange, JT, Thomas, TL. Exposure of prehospital care providers to violence. Prehosp Emerg Care. 1998;2(2):127-131.CrossRefGoogle ScholarPubMed
30. Richards, JR, Ferrall, SJ. Inappropriate use of Emergency Medical Services transport: comparison of provider and patient perspectives. Acad Emerg Med. 1999;6(1):14-20.CrossRefGoogle ScholarPubMed
31. Hauswald, M. Can paramedics safely decide which patients do not need ambulance transport or emergency department care? Prehosp Emerg Care. 2002;6(4):383-386.CrossRefGoogle ScholarPubMed
32. Silvestri, S, Rothrock, SG, Kennedy, D, Ladde, J, Bryant, M, Pagane, J. Can paramedics accurately identify patients who do not require emergency department care? Prehosp Emerg Care. 2002;6(4):387-390.CrossRefGoogle Scholar
33. Rinke, ML, Dietrich, E, Kodeck, T, Westcoat, K. Operation care: a pilot case management intervention for frequent emergency medical system users. Am J Emerg Med. 2012;30(2):352-357.CrossRefGoogle Scholar
34. Gershon, RR, Vlahov, D, Kelen, G, Conrad, B, Murphy, L. Review of accidents/injuries among emergency medical services workers in Baltimore, Maryland. Prehosp Disaster Med. 1995;10(1):14-18.CrossRefGoogle ScholarPubMed
35. Suruda, A, Pettit, T, Noonan, G, Ronk, R. Deadly rescue: the confined space hazard. J Hazard Mat. 1994;36(1):45-53.CrossRefGoogle Scholar
36. Coats, T, Davies, G. Prehospital care for road traffic casualties. BMJ: British Medical Journal. 2002;324(7346):1135.CrossRefGoogle ScholarPubMed
37. Pozzi, C. Exposure of prehospital providers to violence and abuse. J Emerg Nurs. 1998;24(4):320-323.CrossRefGoogle ScholarPubMed
38. Bigham, BL, Jensen, JL, Tavares, W, et al. Paramedic self-reported exposure to violence in the Emergency Medical Services (EMS) workplace: a mixed-methods cross-sectional survey. Prehosp Emerg Care. 2014;18(4):489-494.CrossRefGoogle ScholarPubMed
39. Rahmani, A, Hassankhani, H, Mills, J, Dadashzadeh, A. Exposure of Iranian emergency medical technicians to workplace violence: a cross‐sectional analysis. Emerg Med Australasia. 2012;24(1):105-110.CrossRefGoogle ScholarPubMed
40. Petzäll, K, Tällberg, J, Lundin, T, Suserud, B-O. Threats and violence in the Swedish pre-hospital emergency care. Int Emerg Nurs. 2011;19(1):5-11.CrossRefGoogle ScholarPubMed
41. Grange, JT, Corbett, SW. Violence against Emergency Medical Services personnel. Prehosp Emerg Care. 2002;6(2):186-190.CrossRefGoogle ScholarPubMed
42. Pourshaikhian, M, Gorji, HA, Aryankhesal, A, Khorasani-Zavareh, D, Barati, A. A systematic literature review: workplace violence against emergency medical services personnel. Arch Trauma Res. 2016;5(1).Google ScholarPubMed
43. Bernaldo-De-Quirós, M, Piccini, AT, Gómez, MM, Cerdeira, JC. Psychological consequences of aggression in pre-hospital emergency care: cross sectional survey. Int J Nurs Stud. 2015;52(1):260-270.CrossRefGoogle ScholarPubMed
44. Auerbach, PS, Cushing, TA, Harris, NS. Auerbach’s Wilderness Medicine. Amsterdam, Netherlands: Elsevier Health Sciences; 2016.Google Scholar
45. Tintinalli, JE. Violent patients and the prehospital provider. Ann Emerg Med. 1993;22(8):1276-1279.CrossRefGoogle ScholarPubMed
46. Gallagher, JM, Kupas, DF. Experience with an anonymous web-based state EMS safety incident reporting system. Prehosp Emerg Care. 2011;16(1):36-42.CrossRefGoogle Scholar
47. Sterud, T, Ekeberg, Ø, Hem, E. Health status in the ambulance services: a systematic review. BMC Health Serv Res. 2006;6(1):82.CrossRefGoogle ScholarPubMed
48. Mozaffarian, D, Benjamin, EJ, Go, AS, et al. Executive summary: heart disease and stroke statistics-2016 update: a report from the American Heart Association. Circulation. 2016;133(4):447.CrossRefGoogle ScholarPubMed
49. Field, JM, Hazinski, MF, Sayre, MR, Chameides, L, Schexnayder, SM, Hemphill, R. American Heart Association guidelines for cardiopulmonary resuscitation and emergency cardiovascular care science. Circulation. 2010;122(2):S640-S656.Google Scholar
50. Courtwright, AM, Brackett, S, Cadge, W, Krakauer, EL, Robinson, EM. Experience with a hospital policy on not offering cardiopulmonary resuscitation when believed more harmful than beneficial. J Crit Care. 2015;30(1):173-177.CrossRefGoogle Scholar
51. Miceli, M. Bioethics in practice: unilateral do-not-resuscitate orders. Ochsner Journal. 2016;16(2):111-112.Google ScholarPubMed
52. Vearrier, L. Failure of the current advance care planning paradigm: advocating for a communications-based approach. Paper presented at: HEC Forum 2016.CrossRefGoogle Scholar
53. Mirarchi, FL, Doshi, AA, Zerkle, SW, Cooney, TE. TRIAD VI: how well do emergency physicians understand physician orders for life sustaining treatment (POLST) forms? J Patient Safety. 2015;11(1):1-8.CrossRefGoogle ScholarPubMed
54. National Association of EMS Physicians. POSITION STATEMENT: termination of resuscitation in nontraumatic cardiopulmonary arrest. Prehosp Emerg Care. 2011;15(4):542.CrossRefGoogle Scholar
55. Millin, MG, Khandker, SR, Malki, A. Termination of resuscitation of nontraumatic cardiopulmonary arrest: resource document for the National Association of EMS Physicians position statement. Prehosp Emerg Care. 2011;15(4):547-554.CrossRefGoogle Scholar
56. Hopson, LR, Hirsh, E, Delgado, J, Domeier, RM, McSwain, NE, Krohmer, J. Guidelines for withholding or termination of resuscitation in prehospital traumatic cardiopulmonary arrest. Prehosp Emerg Care. 2003;7(1):141-146.CrossRefGoogle ScholarPubMed
57. Discontinuing Resuscitation in the Out-of-Hospital Setting. ACEP Position Statements Web site. https://www.acep.org/Clinical---Practice-Management/Discontinuing-Resuscitation-in-the-Out-of-Hospital-Setting/. Revised and approved by the ACEP Board of Directors October 2015, June 2008. Accessed March 21, 2017.Google Scholar
58. Ethical Issues in Resuscitation. ACEP Position Statements Web site. https://www.acep.org/Clinical---Practice-Management/Ethical-Issues-of-Resuscitation/. Revised and approved by the ACEP Board of Directors June 2015. Accessed March 21, 2017.Google Scholar
59. Morrison, LJ, Visentin, LM, Kiss, A, et al. Validation of a rule for termination of resuscitation in out-of-hospital cardiac arrest. N Engl J Med. 2006;355(5):478-487.CrossRefGoogle ScholarPubMed
60. Morrison, LJ, Verbeek, PR, Zhan, C, Kiss, A, Allan, KS. Validation of a universal prehospital termination of resuscitation clinical prediction rule for Advanced and Basic Life Support providers. Resuscitation. 2009;80(3):324-328.CrossRefGoogle ScholarPubMed
61. Morrison, LJ, Eby, D, Veigas, PV, et al. Implementation trial of the Basic Life Support termination of resuscitation rule: reducing the transport of futile out-of-hospital cardiac arrest. Resuscitation. 2014;85(4):486-491.CrossRefGoogle Scholar
62. American Heart Association. Web-based Integrated Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care – Part 3: Ethical Issues. ECCguidelines.heart.org. Accessed March 21, 2017.Google Scholar
63. Richardson, DK, Fromme, E, Zive, D, Rongwei, R, Newgard, CD. Concordance of out-of-hospital and emergency department cardiac arrest resuscitation with documented end-of-life choices in Oregon. Ann Emerg Med. 2014;63(4):375-383.CrossRefGoogle ScholarPubMed
64. Ethical Issues at the End of Life. ACEP Position Statements Web site. https://www.acep.org/Clinical---Practice-Management/Ethical-Issues-at-the-End-of-Life/. Reaffirmed and approved by the ACEP Board of Directors April 2014. Accessed March 21, 2017.Google Scholar
65. Morrison, LJ, Bigham, BL, Kiss, A, Verbeek, PR. Termination of resuscitation: a guide to interpreting the literature. Resuscitation. 2008;79(3):387-390.CrossRefGoogle ScholarPubMed
66. Code of Ethics for Emergency Physicians. ACEP Positions Statements Web site. https://www.acep.org/Clinical---Practice-Management/Code-of-Ethics-for-Emergency-Physicians/. Revised and approved by the ACEP Board of Directors June 2016. Accessed March 21, 2017.Google Scholar
67. Sasson, C, Forman, J, Krass, D, Macy, M, Kellermann, AL, McNally, BF. A qualitative study to identify barriers to local implementation of prehospital termination of resuscitation protocols. Circ Cardiovasc Qual Outcomes. 2009;2(4):361-368.CrossRefGoogle ScholarPubMed
68. Zive, D, Koprowicz, K, Schmidt, T, et al. Variation in out-of-hospital cardiac arrest resuscitation and transport practices in the Resuscitation Outcomes Consortium: ROC epistry-cardiac arrest. Resuscitation. 2011;82(3):277-284.CrossRefGoogle ScholarPubMed
69. Govindarajan, P, Lin, L, Landman, A, et al. Practice variability among the EMS systems participating in Cardiac Arrest Registry to Enhance Survival (CARES). Resuscitation. 2012;83(1):76-80.CrossRefGoogle ScholarPubMed
70. Schmidt, TA, Harrahill, MA. Family response to out-of-hospital death. Acad Emerg Med. 1995;2(6):513-518.CrossRefGoogle ScholarPubMed
71. Delbridge, TR, Fosnocht, DE, Garrison, HG, Auble, TE. Field termination of unsuccessful out-of-hospital cardiac arrest resuscitation: acceptance by family members. Ann Emerg Med. 1996;27(5):649-654.CrossRefGoogle ScholarPubMed
72. Edwardsen, EA, Chiumento, S, Davis, E. Family perspective of Emergency Medical Services personnel: a preliminary report. Prehosp Emerg Care. 2002;6(4):440-444.CrossRefGoogle ScholarPubMed
73. Non-Beneficial (‘Futile’) Emergency Medical Interventions. ACEP Position Statements Web site. https://www.acep.org/Clinical---Practice-Management/Non-Beneficial-(-Futile-)-Emergency-Medical-Interventions/. Reaffirmed October 2008 by the ACEP Board of Directors. Accessed March 21, 2017.Google Scholar
74. National POLST Paradigm: Program Status. National POLST Paradigm Web site. http://polst.org/2016-12-20-national-polst-paradigm-program-status/. Accessed March 21, 2017.Google Scholar
75. Schmidt, TA, Hickman, SE, Tolle, SW, Brooks, HS. The physician orders for life-sustaining treatment program: Oregon emergency medical technicians’ practical experiences and attitudes. JAGS. 2004;52(9):1430-1434.CrossRefGoogle Scholar
76. Duncan, J, Taillac, P, Nangle, B, et al. Electronic end-of-life registry: the Utah ePOLST initiative. AIMA Annu Symp Proc. 2013;2013:345-353.Google ScholarPubMed
77. Schmidt, TA, Zive, D, Fromme, EK, Cook, JNB, Tolle, SW. Physician orders for life sustaining treatment (POLST): lessons learned from analysis of the Oregon POLST registry. Resuscitation. 2014;85(4):480-485.CrossRefGoogle ScholarPubMed
78. Mirarchi, FL, Cammarata, C, Zerkle, SW, Cooney, TE, Chenault, J, Basnak, D. TRIAD VII: do prehospital providers understand physician orders for life-sustaining treatment documents? J Patient Saf. 2015;11(1):917.Google ScholarPubMed
79. Clemency, B, Cordes, CC, Lindstrom, HA, Basior, JM, Waldrop, DP. Decisions by default: incomplete and contradictory MOLST in emergency care. JAMDA. 2017;18(1):35-39.Google ScholarPubMed
80. Jesus, JE, Geiderman, JM, Venkat, A, et al. Physician orders for life-sustaining treatment and emergency medicine: ethical consideration, legal issues, and emerging trends. Ann Emerg Med. 2014;64(2):140-144.CrossRefGoogle ScholarPubMed