Ethics in Advanced Prehospital

Week 5

Ethics

• Idea of right and wrong

• Moral duties and responsibilities

• Ideal professional behaviour

Morals

Code of conduct one may follow

Dignity

Pts have the right to autonomy, privacy, safety and respect

Empathy

Understanding and sharing the feelings of others

How could ethics affect a paramedic?

• Paramedics need to be aware that you may be put into situations that go against your moral standards or beliefs

• Paramedics need to be aware that you may be biased to certain situations based on call details alone

• Your moral standards may differ from pts wishes

What do pts feel often in regards to dignity?

Pts often feel their dignity/worth is threatened by age, illness or injury.

Eye Contact

• Strong eye contact may be seen as disrespectful in Asian, Arabic or First Nations cultures

• Downcast eyes from a Hispanic pt may be a sign of respect for authority, age or social position

Personal Space

• People from US, Canada and UK often prefer more personal space

• Those from Latin America, Japan and Middle East may not mind less personal space

Touch

• Hispanic and Arab cultures may forbid a male healthcare worker from touching or examining certain parts of a female’s body

• In some Buddhist cultures, touching the head is impolite since it’s where the spirit resides

Pt Autonomy (Pt can direct their own care)

• Pts have the right to decide if they want medical care

• Pts also have say concerning their end-of-life care

• Pts wants and rights may conflict with our own beliefs

• Pts decision for/against treatment may be against the advice of health care provider

Capacity

• Pts need to have capacity to make decisions on their treatment by understanding their health concerns, the treatments offered and the consequences of not receiving care

• Pts capacity can change over time, requiring reassessment

Consent to Treatment

• Needs to be obtained prior to rendering treatment (pt must be capable of giving consent, consent be informed and voluntary)

• In unconscious pts consent is implied, once capacity is restored, consent must be obtained from pt or substitute decision maker

• Some pts may not understand severity of symptoms and need to be persuaded to be treatment (avoid manipulative comments)

Advance Care Planning

• Pts that become incapable of making decisions still have a right to ‘having a voice’ in their treatments

• Previously expressed wishes can be in oral or written form

• Appointing a substitute decision maker

Power of Attorney for Personal Care

• Legal document designating a person to make health care decisions on behalf of the pt if they are unable to 

• Is not always a family member

Incapacity and Substitute Decision Maker

• If sdm present, treatment/consent will be through them

• Sdm can be person previously appointed by pt, personal outlined in power of attorney for personal care or by default a spouse/partner

End-Of-Life Decisions

• Pts may be palliative and have everything set in place but 911 still activated

• Family members unwilling to grasp death of pt, pt not dying quickly enough

Medical Assistance in Dying (MAID)

• The administering by a medical practitioner or nurse practitioner of a substance to a person, at their request, that causes their death

• The providing by a medical practitioner or nurse practitioner of a substance to a person, at their request, so that they may self-administer the substance and in doing cause their own death

MAID Eligibility

• Be eligible for government-funded health insurance in Canada

• Be 18 years of age or older

• Have a grievous and irremediable condition 

• Have made a voluntary request for MAID that was not made as a result of external pressure

• Give informed consent to receive MAID after having been informed of the means that are available to relieve their suffering, including palliative care

• Individual must be evaluated by two independent health care professionals

• At time of MAID performed, individual must provide informed consent

Grievous and Irremediable Medical Condition

• Serious and incurable illness, disease or disability

• Advanced state of irreversible decline in capability

• Physiological and psychological suffering that is intolerable to the individual

• Natural death is reasonably foreseeable 

Medications Used in MAID

• Midazolam (used for anesthesia and procedural sedation)

• Propofol (anesthetic, short acting medication, decrease LOC and memory of events)

• Rocuronium (muscle relaxant, causes skeletal muscle relaxation)

• Oral drug cocktail in 2022 (5/2000 were given pill version)

DNRs

• Honoured by healthcare providers (paramedics, LTC, FD)

• LTC has different version that paramedics can’t accept

• Must be handed DNR (photocopy, properly filled out and signed, unique serial #, DNR handed over to ED)

• Life-saving interventions listed can’t be performed

Withholding/Withdrawing Resuscitation

• May withhold due to legal paperwork (DNR)

• May discontinue resuscitative efforts after consulting with BHP or getting TOR

• May need to stop someone else from doing CPR if obviously dead

Suspected Child Abuse

• Improper treatment of a child that could harm or put child in risk of being harmed (physical, emotional, sexual abuse)

• Failing to provide basic necessities (food, clothing, shelter)

• Exposing children to drugs/alcohol

• Can be anyone that has care or custody (parent, family, babysitter)

Child Abuse Reporting

• Look/aware of bruises (old, new, multiple), fractures (untreated), head injuries (concussions, unequal pupils), abdominal bruising or tenderness

• Report findings in ACR

• Report endangerment to CAS (override PHIPA) 

Suspected Geriatric Abuse

• Actions causing harm to pt (physical, emotional, sexual abuse)

• Neglect (withholding food, meds, mobility assistance, ignoring, isolating)

• Can be hard to determine (pt may be cognitively unable to complain, fear of being removed from house, pt with mobility issues may have multiple bruises/skin tears)

• Suspicions written in ACR and transferred to hospital staff (ask pt if police intervention wanted)

Suspected Domestic Abuse

• Physical, emotional, sexual, financial, economic

• Be alert when someone answering for pt or pt looking for approval

• If possible, separate pt and do assessment in private

• Notify hospital staff, have police attend

• Write suspicions on ACR

Suspected Sexual Assault

• If underage (police involvement and CAS reporting)

• Pt may have range of emotions

• Advise pt not to clean, bathe, urinate, defecate if possible

• Move pt to quiet place for assessment 

• Leave clothing (any evidence) as untouched as possible

• Be aware assessments may cause fear for pt

• Document on ACR

• Report to receiving facility, ensure police are involved