Ethics in the ER

Tom Blackwell of the National Post has been talking to doctors in the E.R. and to ethicists on the ethical way to treat patients in emergency departments of Canadian hospitals. Here is his article.

“For the physician in Emerg, their number one priority is to rescue and save,” he said. “When faced with the option of not rescuing and not saving, it can sometimes go against their training and intuition and instincts. Having that independent counsel can help them work through their own confusion.”

The patient arrived at the OttawaHospital emergency department with “cataclysmic” medical problems and a perplexing dilemma for the doctors.

The physicians were confident they could fix the person’s potentially fatal ailment, but an “advance directive” document prepared by family to guide health-care staff in such situations called simply for the patient to be sent back home — without receiving any life-saving treatment.

At that point, medical staff did something almost unheard of in emergency medicine: they slowed the frantic pace of treatment and called in the hospital’s bioethicist to help them decide what to do.

It was part of a fledgling project, seemingly unprecedented in North America, to routinely involve ethics professionals in the moral conundrums of the emergency ward, health care’s most hectic, time-crunched environment.

“A lot of what we do is very, very immediate. It’s very action-based rather than reflection-based,” said Dr. Jacky Parker, emergency specialist and prime mover behind the new initiative. “[The project] is an attempt to take ethics from the subliminal to the explicit, so that we can identify issues early and respond to them early.”

Not only is the department routinely calling on Tom Foreman, the hospital’s bioethicist, for “consults” — the type of advice sessions usually sought from medical specialists — but doctors now carry around a card with a checklist of possible ethical challenges.

The project also underscores the plethora of moral conflicts that arise in emergency, but which doctors and nurses in chronically overcrowded departments usually resolve on the fly, with little chance to ruminate.

There are emotional decisions on when to pull the plug on terminal patients, conflicts between loved ones over how aggressively to treat their relative, and drug studies where the critically ill patient is enrolled in the trial first, and asked for their consent later.

The Ottawa experiment also could mark a new role for bioethicists themselves, whom hospitals started to hire in the 1970s after the Karen-Ann Quinlan case called into question the institutions’ ability to handle such prickly issues. The 21-year-old New Jersey woman fell into a persistent vegetative state in 1975 after consuming a cocktail of sedatives and alcohol, but her parents had to fight in court for months to get her removed her from life support, a dispute that triggered headlines worldwide.

Many ethicists still see their role almost as academic overseers, and get directly involved only with cases in the intensive-care unit (ICU) or other wards where patients linger for days or weeks, leaving plenty of time to ponder the arguments, said Mr. Foreman.

“Some ethicists say ‘I don’t do consults by emergency, period … I’m not going to jump and run,’ ” said Mr. Foreman. “I take a very different view. I think if we don’t do that, by the time that episode is over, the emergency doctor has moved on to the next emergency. So, have they learned anything? Have they been helped by the unwillingness to accommodate their need?”

Dr. Parker, a veteran of the emergency department who also obtained a Master’s degree in ethics, surveyed colleagues in her department at the Ottawa Hospital’s Civic campus on whether they needed the help. Most said they could recognize an ethical issue if it arose, but only 10% felt they had time to adequately address it.

The wallet card doctors and nurses now carry asks if they are encountering ethical challenges over such issues as the patient’s ability to consent to treatment, end-of-life care, confidentiality and the fairness of how resources are being allocated, and suggests calling the ethics office if necessary.

In some of the cases that have cropped up since the project started, patients simply refused treatment for serious conditions like a heart attack or stroke, creating significant “moral distress” for the medical professionals. Yet with an ethicist guiding the conversation, and the patient fully informed on the consequences of turning down help, some have been simply let go, she said.

In other situations, two family members with power of attorney over a patient incapacitated by dementia or other problems have disagreed on whether to pursue treatment, one asking that everything possible be done, the other insisting “Mom wouldn’t want that,” she said.

Mr. Foreman said he handles such dilemmas both on the phone and in person if he can get to the department quickly enough.

Emergency physicians elsewhere said they would welcome having access to such expertise, but note there is simply no time for cogitation in some fast-moving situations, or easy solutions to certain ethically questionable situations.

Edmonton’s emergency wards are so packed, doctors often examine patients in the waiting rooms, sometimes sending them directly from the lounge to the operating room with ailments like acute appendicitis, said Dr. Brian Rowe, a University of Alberta professor of emergency medicine. In the process, doctor-patient confidentiality all but vanishes.

“There’s no privacy,” he said. “Your neighbour knows about as much about you as the doctor does. I’m asking someone an ethical question like ‘Are you having intercourse with anybody but your wife or husband?’. That’s not the kind of thing anybody else would hear. … It’s the inhumane treatment of patients that really gets at people.”

Clinical studies in the emergency department, though crucial to improving care and approved in advance by university ethics committees, also raise issues. Because emergency patients often need immediate help and may be incapacitated, they are sometimes enrolled in studies comparing new treatments with existing ones, but before the usual step of asking their consent, said Dr. Rowe. Patients are randomly assigned to one option or the other, as occurred in a recent U.S. study on whether limiting intravenous fluids could prevent some trauma victims from bleeding to death.

“That’s a pretty tough trial. You’ve just been stabbed, so they pull out this envelope [for randomizing research subjects] and it says ‘restricted fluids’ and the paramedics are going ‘What?’ ” said Dr. Rowe. “That’s the kind of trial you would need to do without consent up front. … Even if the person dies, you say, ‘Listen, we did everything we could, we put him in a study, can we use the data?’ Most people will say ‘Yes.’ ”

Emergency specialists say deciding whom to treat first — even in an era of overcrowding — is made relatively easy by well-defined triage protocols, generally avoiding moral conflicts.

It can still be challenging, however, to consider the needs of patients on life support whose deaths are inevitable, especially in the context of limited resources, said Dr. Merril Pauls, both an emergency physician and ethics director in the University of Manitoba faculty of medicine.

“I’m sitting there and I have 40 patients in the waiting room and I have another 20 in beds,” he said. “Someone comes in with an irreversible or untreatable problem and yet the family want to continue some type of resuscitative care …. My resuscitation room is full and I’m trying to have this very challenging conversation with the family.”

The principles of ethics dictate that no one should be denied treatment simply because there might be other patients who need the resources more, said Dr. Pauls. Still, emergency doctors are frequently asked if they can discharge patients to make room for others, he said.

At the OttawaHospital, the ethicist, doctors and family members worked through the dilemma of the sick patient whose directive said to let them go, and in the end the individual received treatment and recovered, said Dr. Parker.

In other instances, however, Mr. Foreman said he has helped doctors come around to a patient’s wish to forego medical help.

“For the physician in Emerg, their number one priority is to rescue and save,” he said. “When faced with the option of not rescuing and not saving, it can sometimes go against their training and intuition and instincts. Having that independent counsel can help them work through their own confusion.”

National Post