Medical Ethical Scenarios

sirengirl

sirengirl

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So today in class we were going over the bioethics and medical legal chapters of my AAOS textbook. Our teacher posed 3 scenarios to us, then divided the classroom in half to have each half argue for or against treatment/transport for the scenarios. They were good ones to get ya thinkin, really more on the ethical parts, so hopefully this doesn't turn into a crazy flamefest on here. These were calls all my medic instructers have actually run over the years. Please note that I am writing these down exactly as they were told to us, I don't have any vitals or patient info to give other than what's here.

Have at it!!


Scenario 1: SNF nurse (who amazingly is calling for her patient :P) calls for 90y/o male choking on a cookie in agonal resps. Upon assessment find strong carotid, unconscious, warm, and pt has a DNR for lung cancer stating no machines, CPR, or RSI. Finger sweep/Magill forceps unable to clear airway. Care about to be terminated when daughter arrives with valid paperwork verifying she is surrogate decision maker, demanding you intubate and recusitate the patient. Your medical director is well known for having a problem with intubated DNR patients. What do you do?

Scenario 2: You have just cleared a early-morning call at the end of your shift. It's 730, and you are enroute to the station to clear out for the day. Stopping at the McDonalds for some coffee, the manager approaches and tells you he has a customer who has vomited and asks if you would check them out. Begrudgingly, you do so. The patient is a 66 y/o male, vomitus evident, diaphoretic, ashen, and SOB. He is well-to-do and his wife is telling him to go to the hospital. He is telling her he won't go. After some convincing, he allows you to assess him, and discover he has audible PE with crackles and unstable vitals. 12 lead shows gross ST elevation in 3 leads, confirming AMI. Pt AOx3 and has refused transport to the point of getting angry. LEO called and will not arrest or detain the patient. Wife cannot persuade him. You and your unit tell him he will likely die if he does not go to the hospital, and he refuses. Contacting online med control, the physician tells you, "I don't care what you have to do, bring me that patient now." The patient insists that if you touch him, he will personally sue you and your partner. What do you do?

Scenario 3: 2am tones for Hospice patient in local nursing home with bowel cancer. Pt unconscious with irregular RR and unstable vitals, valid DNR. 10 family members and hospice representative present with patient. Nursing home demands you transport to the ER, as the facility has a policy forbidding patient death on premesis. Medical control also wants the patient transported to the ER with only pallative measures. Family is up in arms, stating the patient wished to die in his own bed. What do you do?
 
1) I'd call med control, stick the decision on the doctor, but If the daughter has the valid paperwork you have to do it.

2) He's A&O, if he wants to refuse care that's his right, you can't force him to do anything and the doctor can't force you to commit kidnapping. Document the heck outta his refusal and everything you did to try and change his mind.

3)Transport. Patient is alive and OMD wants him transported, if the family doesn't have correct proof of surrogate decision maker they don't really have a say in the matter, its terrible to say but it's true. Politely explain to them why you are doing what your doing. If they are getting really rowdy get PD involved, you don't want to get hurt. This is a pretty awkward position to be in.
 
1. In most systems (and all for power of attorney:health care or conservators), any family member can request resuscitation. In effect, once resuscitation is requested, the patient no longer has a valid DNR.

2. If the patient is A/Ox4, understands the consequences of his actions, and understands the severity of his condition (collectively called capacity), then he can refuse care. The medical control physician cannot order you to violate the law, which forcing the patient to seek care would do.

3. Family has the ability, again, in most systems to make medical decisions. No one is arguing that the patient is or is not a DNR. Leave them at the SNF. The SNF RN cannot force transport, thus leaving the only sticky situation to be the medical control physician.
 
NVRob said:
1) I'd call med control, stick the decision on the doctor, but If the daughter has the valid paperwork you have to do it.

2) He's A&O, if he wants to refuse care that's his right, you can't force him to do anything and the doctor can't force you to commit kidnapping. Document the heck outta his refusal and everything you did to try and change his mind.

3)Transport. Patient is alive and OMD wants him transported, if the family doesn't have correct proof of surrogate decision maker they don't really have a say in the matter, its terrible to say but it's true. Politely explain to them why you are doing what your doing. If they are getting really rowdy get PD involved, you don't want to get hurt. This is a pretty awkward position to be in.
Click to expand...

Agreed on all points. On 2, however, a lot of us agreed that since we would probably then stick around McDonalds for a while- you know, have our coffee, maybe fiddle around with some things in the truck for 10 or 15 minutes ;)- until he conks out and then grab his arse and red light outta there. Cause, y'know, then it's implied consent cause he's not awake to say otherwise :rolleyes:
 
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NVRob said:
1) I'd call med control, stick the decision on the doctor, but If the daughter has the valid paperwork you have to do it.

2) He's A&O, if he wants to refuse care that's his right, you can't force him to do anything and the doctor can't force you to commit kidnapping. Document the heck outta his refusal and everything you did to try and change his mind.

3)Transport. Patient is alive and OMD wants him transported, if the family doesn't have correct proof of surrogate decision maker they don't really have a say in the matter, its terrible to say but it's true. Politely explain to them why you are doing what your doing. If they are getting really rowdy get PD involved, you don't want to get hurt. This is a pretty awkward position to be in.
Click to expand...

couldnt agree more on these answers
 
sirengirl said:
Agreed on all points. On 2, however, a lot of us agreed that since we would probably then stick around McDonalds for a while- you know, have our coffee, maybe fiddle around with some things in the truck for 10 or 15 minutes ;)) until he conks out and then grab his arse and red light outta there. Cause, y'know, then it's implied consent cause he's not awake to say otherwise :rolleyes:
Click to expand...

Some people will argue this though. He competently refused care prior to the event. We talked about this in class and I couldn't get a straight answer out of it. Lawyer said don't touch the pt unless it was a different crew who hadn't seen the pt prior to the collapse and medic instructor said unconscious pt means consent is implied.
 
NVRob said:
Some people will argue this though. He competently refused care prior to the event. We talked about this in class and I couldn't get a straight answer out of it. Lawyer said don't touch the pt unless it was a different crew who hadn't seen the pt prior to the collapse and medic instructor said unconscious pt means consent is implied.
Click to expand...

Fair point. I'm not sure what the mandate around that would be here in Florida, I'll try to remember to ask my instructor on Friday. I'd do it anyways and say, "Hey, I was there, just havin' my coffee that I went there to get anyways, and he passed out..."
 
sirengirl said:
So today in class we were going over the bioethics and medical legal chapters of my AAOS textbook. Our teacher posed 3 scenarios to us, then divided the classroom in half to have each half argue for or against treatment/transport for the scenarios. They were good ones to get ya thinkin, really more on the ethical parts, so hopefully this doesn't turn into a crazy flamefest on here. These were calls all my medic instructers have actually run over the years. Please note that I am writing these down exactly as they were told to us, I don't have any vitals or patient info to give other than what's here.

Have at it!!


Scenario 1: SNF nurse (who amazingly is calling for her patient :P) calls for 90y/o male choking on a cookie in agonal resps. Upon assessment find strong carotid, unconscious, warm, and pt has a DNR for lung cancer stating no machines, CPR, or RSI. Finger sweep/Magill forceps unable to clear airway. Care about to be terminated when daughter arrives with valid paperwork verifying she is surrogate decision maker, demanding you intubate and recusitate the patient. Your medical director is well known for having a problem with intubated DNR patients. What do you do?

Scenario 2: You have just cleared a early-morning call at the end of your shift. It's 730, and you are enroute to the station to clear out for the day. Stopping at the McDonalds for some coffee, the manager approaches and tells you he has a customer who has vomited and asks if you would check them out. Begrudgingly, you do so. The patient is a 66 y/o male, vomitus evident, diaphoretic, ashen, and SOB. He is well-to-do and his wife is telling him to go to the hospital. He is telling her he won't go. After some convincing, he allows you to assess him, and discover he has audible PE with crackles and unstable vitals. 12 lead shows gross ST elevation in 3 leads, confirming AMI. Pt AOx3 and has refused transport to the point of getting angry. LEO called and will not arrest or detain the patient. Wife cannot persuade him. You and your unit tell him he will likely die if he does not go to the hospital, and he refuses. Contacting online med control, the physician tells you, "I don't care what you have to do, bring me that patient now." The patient insists that if you touch him, he will personally sue you and your partner. What do you do?

Scenario 3: 2am tones for Hospice patient in local nursing home with bowel cancer. Pt unconscious with irregular RR and unstable vitals, valid DNR. 10 family members and hospice representative present with patient. Nursing home demands you transport to the ER, as the facility has a policy forbidding patient death on premesis. Medical control also wants the patient transported to the ER with only pallative measures. Family is up in arms, stating the patient wished to die in his own bed. What do you do?
Click to expand...

Scenario 1:
In most locations family members can nullify DNRs, especially proxies. The DNR doesnt exist if its ripped up.

Scenario 2:
Patient has mental capacity? Ask supervisor/med control for assistance on refusal documentation.

Scenario 3:
hospice with a policy forbidding death is an oxymoron...
 
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NVRob said:
3)Transport. Patient is alive and OMD wants him transported, if the family doesn't have correct proof of surrogate decision maker they don't really have a say in the matter, its terrible to say but it's true. Politely explain to them why you are doing what your doing. If they are getting really rowdy get PD involved, you don't want to get hurt. This is a pretty awkward position to be in.
Click to expand...

...yet the SNF RN is not a surrogate decision maker either. Why does the RN get to compel transport over the wishes of the family and hospice representative?
 
NVRob said:
Some people will argue this though. He competently refused care prior to the event. We talked about this in class and I couldn't get a straight answer out of it. Lawyer said don't touch the pt unless it was a different crew who hadn't seen the pt prior to the collapse and medic instructor said unconscious pt means consent is implied.
Click to expand...

My medic and I have waited on scene for someone to pass out before. Patient has severe SOB but refused transport. The son wanted his dad transported. We went back out to the rig to "finish paperwork". About 5 mins later the son runs out saying the dad passed out. And we loaded him up.
 
These are easy:

1. Take em. If a family member has POA paperwork, then at some point either the patient or family decided to give it to them (which is beside the point because any family member can revoke a DNR). I also dislike the yellow DNRs in my state that only require a medical providers (MD, PA, NP) signature to be valid and have no place for family/patient signatures. I'll ignore those in two seconds if a family member requests because for all I know the nursing home's doc signed the DNR without any consent.

2. Leave em. Battery if you touch them. If you're inclined to do so (that is, don't have anywhere better to be), wait til he passes out or codes and then take him under implied consent. Even if the patient expressed a desire to not be transported, the family member can change that the second he passes out.

3. Take em, but this one is more difficult. A DNR is NOT a do not treat form. It does not give family authority to refuse transport, nor is it a request from the patient that you do not transport. If the patients family has POA paperwork at hand, then they can probably refuse the transport. If the patient is under hospice care at the nursing home, then the implication is going to be that they will die at the nursing home, and the ER is going to be extremely unhappy with you taking them there.

In my area, we have two resources that massively uncomplicate this issue. One is the MOST form, which indicates exactly what we can and cannot do (including transport to some degree). The other are dedicated hospice facilities. I have done transports via BLS ambulance to hospice homes with imminently terminal patients from their homes or from nursing homes. These facilities are equipped to offer complete palliative care that nursing homes cannot and will not provide.
 
NVRob said:
Some people will argue this though. He competently refused care prior to the event. We talked about this in class and I couldn't get a straight answer out of it. Lawyer said don't touch the pt unless it was a different crew who hadn't seen the pt prior to the collapse and medic instructor said unconscious pt means consent is implied.
Click to expand...

At that point in time he refused care, but since then there was a change and his conditioned worsened. Reasonable people would assume that if he were able to talk for himself, with the recent "development" that he would change his mind, realize his life was actually in danger and not just a bunch of people trying to scare him into an expensive trip to the hospital, and consent to treatment.

At least that's what I'd assume! :-)

As for the RN not allowing the patient to die in their bed... It's kidnapping if the patient or POA says no, the nurse can't force him to go to the hospital. She can discharge him and then call the cops to have him removed... but she can't force you to take him to the hospital, and I wouldn't touch him. We have left patients in the hospital because they refused transport.

And for the first scenario... Sucks but the POA is the decision maker.
 
In regards to No.2

I think pretty highly of my ability to negotiate with patients like this. I know the scenario assumes nothing has worked but I'd just keep chipping away at him until he came with us. See if we can negate the reasons he doesn't want to go. Play on their (usually considerable) respect for us, "We'll lose our jobs if you don't come to hospital. You seem like a pretty nice reasonable guy :P You don't want us to lose our jobs now do you?". That one always works.
 
Key word: "demand"

In each case the "demander" ("demandor"?) was in the wrong.

By the way, the old "wait 'til they drop" deal actually doesn't apply IF a valid/informed/mentally competent DNR statement is uttered before losing consciousness. Otherwise, NO DNR is valid unless they die while oriented and alert, fighting you off to their last breath.

Following an illegal order is an illegal action.

Use logic and persuasion. Sticking around is OK, but not kidnapping someone because they lost consciousness.

PS: re patient "die in his own bed"...perhaps they meant home, not nursing "home"?
 
mycrofft said:
By the way, the old "wait 'til they drop" deal actually doesn't apply IF a valid/informed/mentally competent DNR statement is uttered before losing consciousness. Otherwise, NO DNR is valid unless they die while oriented and alert, fighting you off to their last breath.
Click to expand...

I believe that the wait till they drop works unless they have a DNR taped to their forehead (or in plain sight on by the patient) or if a family member is standing next to them and presents to you the patient's valid DNR that says you cannot treat the patient. Even then, a DNR doesn't say outright no treatment whatsoever, right?
 
Brown is going to ignore the first and last scenario, we have substantive medicolegal and systemic praxis differences than the US and commenting on them would not be appropriate.

The second bloke at McD's can stay where he is, if he doesn't want to come with us despite all efforts at negotiation then that is his choice. He is a competent patient who has the right to decline our recommendation of treatment/transport, nothing will change that while he is competent and Brown strongly believes in patient choice regardless of situation.
 
A verbal statement would suffice for DNR.

If the pt is oriented and capable of an informed and rational statement, a verbal DNR is binding. If you told the EMT not to resuscitate you, then you woke up after two weeks in an ICU with both legs gone and on a ventilator, would you feel your right to security of your person had been violated.

Ignoring a verbal DNR statement due to absence of a witness would be like declaring any other battery to be legal if there was no witness.

Yeah, without a witness you can tell them there was no utterance, but you might wind up on the witness stand in a civil suit lying to a judge and jury. And maybe joined in there by all your co-workers, friends and family you might have said something to.
 
1) I would continue with full treatment as the DNR is now void on the count of the responsible party with valid paperwork stating she does not want the DNR/DNI to be respected.

2) Continue attempting to persuade Pt. by all possible means. Attempt acquiring consent to treat MONA/FONA. However, if Pt continues to remain AOx4, I'm not transporting. I'd like to be able to treat the next Pt who willingly consents for Tx. and transport in light of an MI and not be facing a judge for charges of kidnapping.

3) Attempt to resolve issue between DON and family. If no responsible party (w/paperwork) near-by, then I will state to the family that they unfortunately do not have a choice in the matter.
 
...and yet no one has answered the question about where the RN gets to make unchallengeable and unilateral treatment choices without consent of the POA or family.
 
JPINFV said:
...and yet no one has answered the question about where the RN gets to make unchallengeable and unilateral treatment choices without consent of the POA or family.
Click to expand...

Is this (3)?

Because that does sound a little tricky, and I guess it depends a little on the legal definition of a "DNR" in the given jurisdiction. If a DNR only comes into effect at the point at which the patient's heart stops, then they get acute treatment / transport.

It's hard, because you have medical control and the RN versus the patient's family, in a situation where arguably they're going to suffer, and it could be potentially litigious. But there's a duty to care there. So I think you have to transport. It's in everyone's interest to try and smooth things out a little, and not get too confrontational.

Now if the DNR in this jurisdiction comes into effect at the point the patient loses consciousness, or it specifies no acute treatment / transport, and this is legal in the given region, then it's time to fight for what's right. This means calling supervision / calling med control, and explaining that what they want you to do is illegal, and are they fully aware of the circumstances and consequences? And trying to mediate between the family and RN. If that doesn't work, you're in a bad place. Refuse transport, and you may lose your job. Transport and you victimise the patient and family, and will be criminally and civially liable.

That's the question really. Is whether there's a document in place rendering it illegal to transport the patient.
 
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