Ethical Issues in EMS

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Ethical Issues in EMS

• David Ross, DO
• Mark Homan, MPA, NREMT-P
• Tim Hurtado, DO
• John Scorsine, JD, EMT-I
• Debra Bennet-Woods, EdD

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Case 1
An EMS crew responds as second ambulance in to an
overturned vehicle on a major roadway 40 minutes
away from the trauma center. There are multiple
critically injured patients. Triage has already
commenced. The crew observes police officers
performing CPR on a child that has already been
removed from the vehicle. The officers bring
this patient to the ambulance. The child is a
male approximately 5 years old.
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The patient is not breathing and has copious
amounts of blood and emesis in the nose and
mouth. No pulses are appreciated with
compressions and pupils are fixed and dilated.
After several minutes, the paramedic decides
that resuscitation efforts are futile and she
receives an order to terminate CPR and a DOA
from medical control. At this point, a 6
month-old child is brought to the ambulance. The
child is awake and crying vigorously. The only
obvious injury is a scalp contusion. The child is
spinally immobilized in preparation for transport.
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Medical command orders the ambulance to depart
immediately for the trauma center with both the 6
month-old and the 5year-old. The ambulance
proceeds using lights and siren.
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Case 1 Questions for the Audience

• Should the 5 year-old be transported to a
  hospital?
• 1. Yes
• 2. No

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Case 1 Questions to Consider 1. Would this
paramedics skills be better utilized by
beginning treatment on other injured patients at
the scene? 2. Should the 5 year-old be
transported to a hospital? 3. If so, should CPR
be restarted? 4. Are lights and siren
indicated? 5. Should the 5-year-olds body be
left at the hospital, taken to the morgue or
brought back to the scene?
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Case 1 Questions for the Audience

• Should the 5 year-old be transported to a
  hospital?
• 1. Yes
• 2. No

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Case 2

• An ambulance and fire responds to a 55 year-old
  male complaining of chest pain. They find the
  patient sitting on bench at a bus stop. The crew
  suspects that he is homeless.

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The patient relates central chest pain that is
about 7/10 with radiation into the left shoulder
and arm. Vital signs include a blood pressure of
150/90, pulse of 88, respirations 22. Other than
diaphoresis, the rest of the physical exam is
negative. The patient agrees to transport.
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Prior to departure, this ECG is obtained.
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Enroute to the hospital, the patient tells the
paramedic that he has changed his mind and does
not want to go to the hospital. Further, he
insists that the crew stop the ambulance and
allow him to exit onto the sidewalk.
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Case 2 Questions for the Audience

• Would you allow this patient to refuse care?
• Yes
• No

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Case 2 Questions to Consider 1. How should the
crew handle this situation? 2. Does the patient
meet criteria to refuse care? 3. What
complications does the apparent lack of a home or
friends bring to this situation?
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Case 2 Questions for the Audience

• Would you allow this patient to refuse care?
• Yes
• No

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Case 3

• EMS and fire respond to a call regarding a 79
  year-old female with altered mental status. Upon
  arrival, the crews note a frail woman apparently
  in the care of her daughter who lives with the
  patient. The daughter states the patient has
  required more attention as she has progressively
  more confused and has been falling more. On the
  day prior, the daughter thinks the patient may
  have hit her head.

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The patient is disoriented only mumbles
inappropriately but says that she does not want
to leave the home. The physical exam demonstrates
multiple bruises in various phases of healing.
She has facial and scalp abrasions and
contusions. She has several old extremity
lacerations. Vital signs are stable. The
patient smells of urine and feces. The crews note
that the home is extremely cluttered and it is
only possible to walk down a very narrow pathway
in the home because of magazines, boxes and other
items lined high in the corridors and rooms of
the home. Cat urine and feces are seen on the
floors.
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Case 3 Questions for the Audience

• Would you allow this patient to refuse care?
• Yes
• No

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Case 3 Questions for the Audience

• Does EMS have a legal obligation to report
  concerns in this case?
• Yes
• No

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Case 3 Questions to Consider

• 1. Does this patient have the capacity to refuse
  transport?
• 2. What should the EMS crews consider in this
  situation besides providing immediate medical
  care and transport?
• 3. What are the ethical considerations for the
  crew in this case?
• 4. What are the legal considerations in Colorado
  with respect to EMS in this case?

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Case 3 Questions for the Audience

• Would you allow this patient to refuse care?
• Yes
• No

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Case 3 Questions for the Audience

• Does EMS have a legal obligation to report
  concerns in this case?
• Yes
• No

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Case 4

• A 41 year-old unrestrained female is critically
  injured after being involved in a head-on motor
  vehicle collision. Family members that were not
  injured are hysterical at the scene.
• On scene EMS and Fire suspect multi-system
  trauma as the patient has a Glasgow Coma Scale of
  4, a blood pressure of 70/palp and a carotid
  pulse of 120. No oxygen saturation can be
  obtained.
• Normal extrication, assessment and treatment are
  initiated on-scene before a twenty-five minute
  lights and siren transport to the trauma center.

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Enroute, she is easily intubated by one of the
paramedics. He feels that he saw the endotracheal
tube pass the vocal cords. He did not use an
esophageal detection device. The capnography wave
is persistently low, less than 10. Although it is
somewhat hard to hear in the ambulance, his
paramedic partner says he hears equal breath
sounds. About 10 minutes prior to arrival at the
hospital, the patient becomes bradycardic and
then goes into cardiac arrest. CPR is begun.
During the resuscitation, the paramedic begins
wonder if the ETT is in the trachea. But then
dismisses the thought.
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The patient is ultimately pronounced dead in the
ED. The physician then confidentially tells the
paramedic that the endotracheal tube was in the
esophagus and that this could have contributed to
the cardiac arrest. As they are leaving the ED,
the crew sees the family arriving.
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Case 4 Questions for the Audience

• Should EMS talk to the family as they leave the
  ED?
• Yes
• No

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Case 4 Questions for the Audience

• If so, should the EMS crew advise the family that
  they may have placed the ETT in the esophagus?
• Yes
• No

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Case 4 Questions for the Audience

• Should the EMS agency address the issue with the
  family after investigating the circumstances?
• Yes
• No

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Case 4 Questions to Consider

• 1. Should the EMS crew speak to the family?
• 2. If so, what should they say?
• 3. Should they tell the family that the airway
  tube they placed might have been in the esophagus
  and what that could have meant to the patient?
• 4. Should the EMS agency address the issue with
  the family after investigating the circumstances?
• 5. What legal protections (if any) do healthcare
  providers have in Colorado in discussions with
  families or guardians and saying Im sorry
  after an adverse patient outcome?
• 6. If there are any laws, do they also apply to
  EMS?

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Case 4 Questions for the Audience

• Should EMS talk to the family as they leave the
  ED?
• Yes
• No

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Case 4 Questions for the Audience

• Should the EMS agency address the issue with the
  family after investigating the circumstances?
• Yes
• No

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Case 4 Questions for the Audience

• Should the EMS agency address the issue with the
  family after investigating the circumstances?
• Yes
• No