Ethics in Emergency Medicine

Dr. Amalia Muhaimin, MSc.

(Bioethics)
Department of Bioethics
School of Medicine, Faculty of Medicine and
Health Sciences
Universitas Jenderal Soedirman
 Differences between Emergency and
Primary Care Practice (Iserson, 2004)
Emergency Practice Primary Care Practice
Brought in by ambulance, police, etc. Patients choice to enter service
Patient does not choose physician Patient chooses physician (?)
ED personnel do not know patient Often know patient+values
Patient experiences acute change Patient has chronic medical problems
Anxiety, pain, alcohol and altered mental Less frequent
status are frequent
Decisions are made quickly Time for discussion+ deliberation
Decisions made independently Greater opportunity to consult
Physician represents institution Represents self or medical group
Environment open + less controlled Work environment private+controlled
Stressful work schedule Schedule often set
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 Emergency patients rely heavily on
the interpersonal skills, moral
behavior, emotional maturity,
goodwill, and ethical capacity of
emergency providers. (Larkin,
1999)

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 Ethical issues related to emergency
medicine:

1. Informed Consent and Refusal

2. Patient Decision Making Capacity
3. Treatment of Minors
4. Advance Directives
5. Limiting Resuscitation
6. Futility
7. Confidentiality
8. Truth Telling and Communication
9. Compassion and Empathy
10.Moral Issues in Disaster Medicine
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 1. Informed consent &
refusal
The Emergency Rule
1. Patient unconscious or otherwise
incapable of consenting exception
to informed consent

2. Limited time emergency services

operate under the moral imperative
of beneficence, acting in the best
interests of the patient.

3. In time of life threatening crisis

physician's duty to do that which
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the occasion demands, even
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without
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 How urgent?

How urgent a situation is

depends upon:
- consequences of a delay in
giving treatment,
or
- consequences of a failure to
give any treatment at all.

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 Refusal
1. Patients with decision making
capacity (capacity) have a right
not to consent to care.

2. The elements of a valid, informed

refusal are the same as consent:
capacity & comprehension of
information (risks & harm)

3. Refusal of care may conflict with

physicians judgment &
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recommendation emphasize the
 4. Both consent and refusal must be
made voluntary, without
coercion/duress.

5. Physicians should provide

treatment despite:
- a verbal refusal in patients with
no capacity, or
- life threat is so acute no time to
assess refusal.

6. When patients do not have capacity

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the
 2. Patient Decision Making
Capacity
Define decision making
capacity
Contrast medical
interpretations of decision
making capacity with the legal
definition of competence
List the ways decisions can be
made when a patient lacks
decision-making capacity
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 The Medical Concept of Decision
Making Capacity
All adult patients unless there is evidence
obtained by history, behavior, or physical
examination
The determination of decision making
capacity requires that:
1. The patient appreciates he/she has the
power to make decisions on his/her behalf
2. The patient understands
- the medical situation & prognosis,
- the nature of the recommended evaluation
or care,
- the alternatives,
- the risks & benefits of each, and
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the likely
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3. The patient's decision is stable over time,
 Level of capacity

The degree/level of decision-making

capacity varies with the degree &
probability of risk, benefit, &
patient's decision to
consent/refuse.

The greater the risk the more

exacting the standard of capacity
A patient might need a low level of
capacity to consent to a procedure
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and
 The Concept of Legal
Competence?

Each state may have slightly

different criteria for the
determination of competence
How about Indonesia??

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 When a Patient Lacks Decision-Making
Capacity

How should medical decisions be

made?
depends on:
- the speed with which the decision
must be made
- what information about patient
preferences is available

When patients previously

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expressed wishes are known,
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 Case Study:
60 y.o. referred from private hospital
with (suspect of) CRF (7 days of
hospitalization, askeskin)
Arrived in E.R. unconscious
(somnolen, GCS 12), suspect of
metabolic disorder
Latest lab results reveal normal,
doctors advise head CT-scan to find
etiology & establish diagnosis
Wife disagrees (wishes for
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but children agrees
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 3. Limiting Resuscitation
"Do Not Resuscitate Order" (DNR
order)
Withholding & withdrawing: no moral
difference
Legally+ethically acceptable to
withhold resuscitation attempts on
patients who have expressed clear
wishes (Indonesia?)
Challenge communication must
be legally, ethically, and medically
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 Emergency setting patient's
wishes, medical condition, and
prognosis are usually unknown.

If there is doubt resuscitative

efforts should be initiated.

The decision to resuscitate must be

an immediate yes or no decision.

"Slow codes," suboptimal effort, or

delayed intervention are never
medically or ethically acceptable.
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 Reference
Larkin GL. Evaluating Professionalism in Emergency
Medicine: Clinical Ethical Competence. Academic
Emergency Medicine ,1999; 6:302-11
Rucoba, RJ. Ethical, legal concerns for emergency medical
care. AAP News, 25 July 2011
SAEM Ethics Committee Ethics Curriculum for Emergency
Medicine Residencies,1994
Iserson KV. Ethical Considerations in Emergency Care.
Israeli Journal of Emergency Medicine, 2004; 4: 10-17
Pauls M et al. Ethics in the trenches: Part 2. Case studies of
ethical challenges in emergency medicine. Can J Emerg
Med, 2004;6(5):363-6
Marco CA et al. Ethics Curriculum for Emergency Medicine
Graduate Medical Education. The Journal of Emergency
Medicine, 2010; pp. 17
17 Franklin
Blok ECCE 2JS et al. Ethical Dilemmas in Emergency
24/05/2013Medicine.
Emergency Medicine and Critical Care, 2008; 12-14