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Ethical Considerations in Emergency Care - ISRJEM

MESH Words:Ethics, Bioethics, Emergency Medicine, Advance Directives, Values,Surrogates, DNRP hysicians worldwide are embracing Emergency medicine as a specialty and thisawakening interest has brought with it a concomitant flurry of new programs andpractitioners. While, as an intensely clinical specialty, Emergency physicians mustacquire significant medical expertise, the Emergency Department (ED) is also a site atwhich Ethical dilemmas inevitably arise where life may be so evanescent that it issometimes difficult to pinpoint when death occurs. Educating ourselves to respond to themany types of Ethical challenges is a no less important aspect of Emergency medicine. Emergency physicians, nurses, medics and corpsmen slog together through the emergencydepartment battleground.

Emergency Medicine Ethics behind modern developments, the bioethical construct allows a greater flexibility in decision making. This is a crucial factor in the crucible of the emergency room,

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Transcription of Ethical Considerations in Emergency Care - ISRJEM

1 MESH Words:Ethics, Bioethics, Emergency Medicine, Advance Directives, Values,Surrogates, DNRP hysicians worldwide are embracing Emergency medicine as a specialty and thisawakening interest has brought with it a concomitant flurry of new programs andpractitioners. While, as an intensely clinical specialty, Emergency physicians mustacquire significant medical expertise, the Emergency Department (ED) is also a site atwhich Ethical dilemmas inevitably arise where life may be so evanescent that it issometimes difficult to pinpoint when death occurs. Educating ourselves to respond to themany types of Ethical challenges is a no less important aspect of Emergency medicine. Emergency physicians, nurses, medics and corpsmen slog together through the emergencydepartment battleground.

2 Their rapid decisions can save lives or not, ease suffering orprolong inevitable deaths, wastefully expend resources on futile efforts or conserve them forthose who can benefit and promote respect for patients as persons or yield to theever-lurking and ego-enhancing desire to exercise power and control over reflection is not typically a part of Emergency medicine practice. As one Israeliinternist-bioethicist perceptively observed, Emergency medicine is comprised ofdisciplined practice of routines and guidelines under conditions of uncertainty, pressureand time limits. More than any other medical area, Emergency physicians learn to act automatically , faster than the speed of philosophical thinking.

3 (1) Indeed, emergencyphysicians have a markedly different relationship with patients than do otherpractitioners, especially others providing primary care (Table 1) (2, 3). Emergencyphysicians often care for patients who are unfamiliar to them and to the practitioners, who either know their patients or who care for them in lessacute settings, often have other mechanisms for making Ethical decisions, emergencyphysicians generally havelimited , it should come as nosurprise that our specialty sgreatest Ethical failing is that weoften do not recognize problemsthat confront us as being in theethical, rather than in the strictly medical, realm. Our secondfailing is misperceiving ethicseither as what secular orreligious law commands, or as adiscipline that describesirresolvable moral precepts thatunderpin Ethical decisions arederived from a wide variety ofsources, including individual,cultural and communal valuesystems.

4 Unlike the law, whichis relatively rigid and,particularly in the case ofscientific and medical issues,can lag years or even decades10 Israeli Journal of Emergency Medicine Vol 4, No. 2, June 2004 Ethical Considerations in Emergency CareKenneth , MD, MBA,FACEPP rofessor of EmergencyMedicine, Director, ArizonaBioethics Program,University of Arizona,Tucson, AZ, USAC orrespondence: Dr. Kenneth V. IsersonProfessor of EmergencyMedicine Director, ArizonaBioethics ProgramUniversity of ArizonaTucson, AZ 85724 USA(520) 626-2398E-mail: 1: Differences between Emergency and Primary care PracticeEmergency Practice Primary care Practice Patient often brought in by ambulance, Patient chooses to enter medical care or family. Patient does not choose physician.

5 Patient chooses physician. ED personnel must gain patient trust. Physician and nurses already enjoy patient s confidence and trust. ED personnel do not know patient, family Physician and nurses often know patient,or values. family and values. Patient experiences an acute change in health. Patient has chronic medical problems. Anxiety, pain, alcohol and altered mental Anxiety, pain, alcohol and altered mentalstatus are frequent. status are less frequent. Decisions are made quickly. There is more time for discussion and deliberation. Physician makes decisions independently. Physician has a greater opportunity to consultwith patient, family, other physicians, ethics committees, lawyers, courts and ethicists. Physician represents institution and medical staff.

6 Physician represents self or medical group. Work environment is open and less controlled. Work environment is private and controlled. ED personnel frequently have a stressful Work schedule often set or canceled by work schedule. from (same information as in Reference 2) Emergency Medicine Ethicsbehind modern developments, the bioethical constructallows a greater flexibility in decision making. This is acrucial factor in the crucible of the Emergency room,which demands reasonable action. Emergency physicians(EPs) are often called on to integrate a patient s personal,cultural, religious, or community values and to balancethem with their own personal and professional ethos. Aworking knowledge of bioethics greatly enhances the EP sability to make reasonable, Ethical decisions in the limitedtime frame common to Emergency medical ethics and its application to Israeliemergency medicine is not premature.

7 However, it is donewith the recognition that Emergency medicine in Israel hasnot yet matured to the point of having a unified approachto patient care . Much like most Emergency departments inthe United States until the mid-1980s, Israeli patientscontinue to be distributed to various specialty physiciansbased on their presenting symptoms (1). In itself, this mayserve to diminish some patients to the sum of their chiefcomplaint in the eyes of healthcare workers. When betterthan now to try to reverse this perception?This paper will address a number of common ethicaldilemmas that arise in Emergency medicine, especiallythose relating to the elderly. What follows will be a briefdiscussion of what constitutes bioethics, the derivation andimportance of patient values, the differences betweenwithholding and withdrawing treatment in emergencymedicine, futility issues, surrogacy and advancedirectives.

8 Finally, there is a discussion of how to use thisand additional Ethical knowledge in Emergency medicinepractice to act in the face of relative uncertainty. Thisincludes the description of a rapid Ethical decision-makingmodel for Emergency medicine and a brief comment on prospective ethics, that is, changing the law to resolveethical issues that commonly is bioethics?Ethics is the application of values and moral rules tohuman activities. Bioethics is a subset of ethics that usesethical principles and decision making to solve actual oranticipated moral dilemmas facing clinicians in medicineand biology using reasoned and defensible professional etiquette, which relates to standardsgoverning the relationships and interactions betweenpractitioners, bioethics deals with relationships betweenpractitioners and patients, practitioners and society andsociety and patients (4).

9 Modern bioethics has developed during the last fourdecades largely because the law has often remained silent,inconsistent, or morally wrong on matters vital to thebiomedical community. The rapid increase inbiotechnology, the failure of both the legal system and thelegislatures to deal with new and pressing issues and, inthe United States, the increasing liability crisis has driventhe medical community to seek answers to some of thedifficult questions practitioners have had to work throughon a daily basis (4).It is said that good ethics makes good law, but that goodlaw does not necessarily make good ethics. How doesbioethics differ from law, both of which incorporatesocietal values?

10 Laws are rules of conduct establishedby legislatures, administrative agencies, courts or othergoverning bodies. They often vary from locale to localeand are enforceable in the jurisdiction where theyprevail. Ethics incorporates the broad values and beliefsof correct conduct. Although bioethical principles do notchange because of geography (at least not within oneculture), interpretation of the principles may evolve associeties change. Significant overlap exists betweenlegal and Ethical decision making, frequently on basicissues (5), although they also differ significantly(Table 2).Although bioethics is neither law nor religion, itabsorbs and applies elements of both, as well as theoriesand principles from various philosophical schools.


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