When patients come to the emergency department for the care of their ailments, they are very vulnerable. They have to deal with doctors and nurses that they have never met before, they are nervous about the situation they are in, and they are concerned about the outcome of this interaction. They want to rely on the system yet they are concerned from a clinical, financial, and ethical standpoint. This article will cover the ethical perspective and shed some light on how to make the visit as smooth and as caring as possible.
Ethics deals with the behavior of individuals and encompasses the rules that describe what is considered right and wrong. Ethical principles are well-defined and well-documented across the board. It is good practice to follow those rules, it also ensures the safety of the patients as well as the medical staff themselves.
ETHICS of Emergency Care.
Autonomy: It is the backbone of ethics. Everyone has the fundamental right to choose what happens to their body. So any time we treat anyone in the emergency department we need to make sure we do that with the consent of the patient. The consent is of three types.
a) Implied consent.
b) Verbal consent.
c) Written consent.
Implied consent: When patients come to the emergency department it is safe to assume that they are here to be seen and treated. This is called implied consent. Their presence is taken as consent. But this only means that we can evaluate them, examine them and give them prescriptions. Anything other than those customary steps needs a second level of consent. As treating doctors and nurses we need to know the full extent of implied consent. We should also be cognizant of the circumstances as at times the situation in which it seems like the consent may have been implied turns out not to be the case. Like treating the elderly on instructions of their children but against their wishes and so on.
Verbal consent: When a doctor or a nurse treats a patient, it is a good practice to have communication with your patient and involve them in the process of treatment. Although it is generally accepted that the patients coming to the Emergency Department come to get treated, still explain gently for permission to treat them. Most minor procedures require verbal consent and that includes intravenous line placement, Nasogastric tube placement, foley catheterization, and any back-slab placement. Anything that is considered an invasive procedure requires written consent. Depending upon the setting, it is also a good practice to keep the patients in the loop about the expenses and let them know when any expensive test has been ordered like a CT scan or an MRI, or a lab test that would cost more than expected. It is the patient’s right to know the cost that they will incur after the treatment is finished.
Written consent: All invasive treatments, including, but not limited to intubation, chest tube placement, central line placement, and any joint tap or similar procedure should be documented, and consent should be taken in writing. When consent is being taken, it should be ‘informed consent’, which means the patient should be aware of the reason why certain procedures are being done, the complications of that treatment, the consequences of refusing it, and the alternatives, and also know the consequences of taking the alternative. It effectively means that the patient makes a decision based on proper knowledge, and not based on the persuasion of the treating physician.
Do no harm: Non-maleficence is doing no harm and is one of the essential cornerstones of emergency care. The staff, including the nurses and the doctors, make difficult decisions regarding the patients, and some of those decisions may be painful to carry out, but the actual intention of the treating doctor or nurse is to benefit the patient, and do no harm.
Do good to the patient: The healthcare staff, including the nurses, and the doctors are all expected to act in the best interest of the patient. They make decisions that have far-reaching consequences, and sometimes some of those decisions may not turn out to be exactly how they intended so it is very important that the doctors and nurses are seen doing good for the patient. This happens always through communication and explaining the actions so that the patients are confident about their decision-making as well as the intentions of their healthcare providers.
Justice: In most of the hospitals and emergency departments across the globe, the healthcare providers and resources are always limited, and the patient load may be very high or infinite at times. To provide the best care to everyone, we have to act on the principle of justice. The justice principle can be best explained in one expression, which is ”to do most for the most”. Acting on this principle, sometimes we have to let go of the treatment of someone who cannot be saved and give those resources and care to another person whose life seems salvageable. It is difficult to always do justice as we have to rely on limited data and at times on different situations that we may not have seen altogether in our lives, and still have to come up with a decision that is seen as just.
Ethics of Interaction: Two basic principles will be shared here.
Confidentiality: During the course of treating patients or dealing with emergencies, we come across plenty of information about the patient. Most of those history points or pieces of information are not known to other people, and at times not to immediate family members. This demands that we act on strict confidentiality principles. It is the right of the patient that whatever information he or she is giving to their healthcare providers would not be shared with anyone else. All information regarding the patient should be kept confidential unless the patient authorizes to do so, or only shared for legal purposes in case of any legal requirement.
Respect: Emergency care provision may lead to situations, where the patients may not be comfortable. This involves being in very close proximity to them or dealing with their body in different ways. It is of utmost importance to be respectful in providing care, and also respectful of their social, moral, and religious boundaries. If good care can be rendered without compromising the patient’s boundaries, then that’s best, otherwise, the patient should be explained the situation and let them decide the flow of interaction if permissible. Life-threatening emergencies should be dealt with extreme respect especially when patients are not able to consent.
Situational awareness: Every emergency comes with unique challenges, and as emergency care providers we should always guard our conduct and our interaction with the patients should respect law and society morale.
Act within the boundaries of law: Any emergency situation is stressful, yet the emergency care providers should be trained to act based upon the legal requirements and not exceed them. The patients may have medicolegal issues that can not easily be understood or some other problems that require a deeper understanding of the law e.g. domestic violence, partner violence, elderly abuse, child abuse, deliberate self-harm, and some others that need working within the law boundaries. We should familiarize ourselves with these laws and act within the boundaries.
Act within the boundaries of society: Each society has its norms, and people serving in the emergency department should know and respect that. It is the right of the patients that their personal values are to be respected. Gender issues, elderly consent, family dynamics, and financial and social dynamics are the routine points of contention that are seen in the emergency departments, and we should be familiar with the solutions to these.
The ethical framework may be seen as a challenging part of providing emergency care, yet it is not only the right of the patient to be treated ethically but also in the best interest of the doctors, nurses, and institutions to follow the ethics when dealing with patients.