How prehospital emergency personnel manage ethical challenges: the importance of confidence, trust, and safety.

BACKGROUND: Ethical challenges constitute an inseparable part of daily decision-making processes in all areas of healthcare. Ethical challenges are associated with moral distress that can lead to burnout. Clinical ethics support has proven useful to address and manage such challenges. This paper explores how prehospital emergency personnel manage ethical challenges. The study is part of a larger action research project to develop and test an approach to clinical ethics support that is sensitive to the context of emergency medicine. METHODS: We explored ethical challenges and management strategies in three focus groups, with 15 participants in total, each attended by emergency medical technicians, paramedics, and prehospital anaesthesiologists. Focus groups were audio-recorded and transcribed verbatim. The approach to data analysis was systematic text condensation approach. RESULTS: We stratified the management of ethical challenges into actions before, during, and after incidents. Before incidents, participants stressed the importance of mutual understandings, shared worldviews, and a supportive approach to managing emotions. During an incident, the participants employed moral perception, moral judgments, and moral actions. After an incident, the participants described sharing ethical challenges only to a limited extent as sharing was emotionally challenging, and not actively supported by workplace culture, or organisational procedures. The participants primarily managed ethical challenges informally, often using humour to cope. CONCLUSION: Our analysis supports and clarifies that confidence, trust, and safety in relation to colleagues, management, and the wider organisation are essential for prehospital emergency personnel to share ethical challenges and preventing moral distress turning into burnout.

Non-technical skills in paramedicine: A scoping review.

This scoping review aims to identify which non-technical skills have been empirically identified in the literature, to create the first list of empirically identified non-technical skills for paramedics and allied health personnel. A five-stage scoping literature was undertaken in March 2020. The search retrieved a total of 4756 citations. A total of 93 studies met the inclusion criteria and were analyzed for data charting. A total of 26 non-technical skills were identified in the literature. The top five non-technical skills included decision-making (33%, n = 31), communication (24%, n = 23), empathy (17%, n = 16), leadership (12%, n = 12), and ethics (10%, n = 10). Furthermore, only five studies investigated the assessment or measurement of non-technical skills. This scoping review identified 26 non-technical skills that had been investigated in the paramedic literature to create the first list of empirically based desirable non-technical skills for a paramedic. Subsequently, research can then begin to focus on identifying the link that these have to paramedic practice and patient safety.

Do Paramedics Have a Professional Obligation to Work During a Pandemic? A Qualitative Exploration of Community Member Expectations.

OBJECTIVES: Previous research has identified a lack of clarification regarding paramedic professional obligation to work. Understanding community expectations of paramedics will provide some clarity around this issue. The objective of this research was to explore the expectations of a sample of Australian community members regarding the professional obligation of paramedics to respond during pandemics. METHODS: The authors used qualitative methods to gather Australian community member perspectives immediately before the onset of the coronavirus disease 2019 (COVID-19) pandemic. Focus groups were used for data collection, and a thematic analysis was conducted. RESULTS: The findings revealed 9 key themes: context of obligation (normal operations versus crisis situation), hierarchy of obligation (individual versus organizational obligation), risk acceptability, acceptable occupational risk (it's part of the job), access to personal protective equipment, legal and ethical guidelines, education and training, safety, and acceptable limitations to obligation. The factors identified as being acceptable limitations to professional obligation are presented as further sub-themes: physical health, mental health, and competing personal obligations. CONCLUSIONS: The issue of professional obligation must be addressed by ambulance services as a matter of urgency, especially in light of the COVID-19 coronavirus pandemic. Further research is recommended to understand how community member expectations evolve during and after the COVID-19 coronavirus pandemic.

When Good Women Decide to Do Nothing.

Many health professions students struggle with deciding whether and when to challenge their teachers. This graphic memoir, When Good Women Do Nothing, conveys what happened one day in the life of a paramedic student called to help an incarcerated, handcuffed woman in labor who gave birth on a stretcher. The memoir documents numerous clinical and ethical disagreements and decision points throughout the paramedic team's time with this patient.

Ethical aspects of collateral clinical services by non-credentialled personnel in international medical crises.

The study of global responses to medical crises in developing and under-developed countries demands reflection about the ethical engagement of non-credentialled medical personnel in the context of clinical care. The need for, and the desire to contribute by, people and organisations that lack demonstrable or readily transferable credentialed skills must be reconciled with the ethical administration of collateral clinical services. The urgent need for the provision of such services must neither preclude their use nor permit their use irrespective of salient ethical considerations. One way to explore these issues is to examine a recent exemplar of a non-governmental organisation's utilisation of non-credentialled medical personnel during the Ebola outbreak in Sierra Leone. Although the group lacked clinical proficiency (apart from community health workers), it collaborated with experts in interment to train staff to bury those who had succumbed to the disease in respectful and hygienic individually marked graves. The group leveraged its cultural competency and in-country presence to deploy staff judiciously, support the workers to combat social ostracism and offer vocational and other education to help them assimilate back into the workforce once the outbreak subsided. The non-governmental organisation stepped up to do the work that others shunned, and to do it ethically and proficiently. I offer the work to show a compelling and innovative blueprint for ethical mobilisation of non-credentialed healthcare personnel in a global medical crisis.

A Qualitative Study of Paramedic Duty to Treat During Disaster Response.

OBJECTIVES: Disasters place unprecedented demands on emergency medical services and can test paramedics personal commitment as health care professionals. Despite this challenge, guidelines and codes of ethics are largely silent on the issue, providing little to no guidance on what is expected of paramedics or how they ought to approach their duty to treat in the face of risk. The objective of this research is to explore how paramedics view their duty to treat during disasters. METHODS: The authors employed qualitative methods to gather Australian paramedic perspectives. RESULTS: Our findings suggest that paramedic decisions around duty to treat will largely depend on individual perception of risk and competing obligations. A code of ethics for paramedics would be useful, but ultimately each paramedic will interpret these suggested guidelines based on individual values and the situational context. CONCLUSIONS: Coming to an understanding of the legal issues involved and the ethical-social expectations in advance of a disaster may assist paramedics to respond willingly and appropriately. (Disaster Med Public Health Preparedness. 2019;13:191-196).

Ionising radiation risk disclosure: When should radiographers assume a duty to inform?

INTRODUCTION: Autonomy is a fundamental patient right for ethical practice, and informed consent is the mechanism by which health care professionals ensure this right has been respected. The ethical notion of informed consent has evolved alongside legal developments. Under Australian law, a provider who fails to disclose risk may be found to be in breach of a duty of disclosure, potentially facing legal consequences if the patient experiences harm that is attributable to an undisclosed risk. These consequences may include the common law tort of negligence. Ionising radiation, in the form of a medical imaging examination, has the potential to cause harm. However, stochastic effects cannot be attributable to a specific ionising radiation event. What then is the role of the Australian medical imaging service provider in disclosing ionising radiation risk? METHODS: The ethical and legal principles of informed consent, and the duty of information provision to the patient are investigated. These general principles are then applied to the specific and unusual case of ionising radiation, and what responsibilities apply to the medical imaging provider. Finally, the legal, professional and ethical duties of the radiographer to disclose information to their patients are investigated. RESULTS: Australian law is unclear as to whether a radiographer has a common law responsibility to disclose radiation risk. There is ambiguity as to whether stochastic ionising radiation risk could be considered a legal disclosure responsibility. CONCLUSION: While it is unlikely that not disclosing risk will have medicolegal consequences, doing so represents sound ethical practice.

The Cost of Conscience.

The spread of demands by physicians and allied health professionals for accommodation of their private ethical, usually religiously based, objections to providing care of a particular type, or to a particular class of persons, suggests the need for a re-evaluation of conscientious objection in healthcare and how it should be regulated. I argue on Kantian grounds that respect for conscience and protection of freedom of conscience is consistent with fairly stringent limitations and regulations governing refusal of service in healthcare settings. Respect for conscience does not entail that refusal of service should be cost free to the objector. I suggest that conscientious objection in medicine should be conceptualized and treated analogously to civil disobedience.

The importance of reliable information exchange in emergency practices: a misunderstanding that was uncovered before it was too late.

BACKGROUND: Many medical emergency practices are regulated by written procedures that normally provide reliable guidelines for action. In some cases, however, the consequences of following rule-based instructions can have unintended negative consequences. The article discusses a case - described on a type level - where the consequences of following a rule formulation could have been fatal. CASE PRESENTATION: A weak and elderly patient has cardiac arrest, and a Do Not Resuscitate (DNR) clause is written in the patient's medical record. Paramedics at the scene cannot see that the patient's general appearance match conditions which would indicate the DNR clause, so they start cardiopulmonary resuscitation (CPR), and the patient survives. This turns out to be a crucial decision. The DNR clause is from an earlier bout with serious disease from which the patient has recovered, against all odds, and someone has forgotten to remove the clause from the medical record. ANALYSIS: In order to be able to interpret the validity of written guidelines, paramedics and other health workers need to develop personal skills that transcend the ability simply to follow written instructions. Within traditional virtue ethics, personal judgment is conceived of as crucial for being able to make 'good' autonomous decisions. Virtue ethical analyses, decision-making abilities and non-technical communication skills are important as conceptual tools when health workers need to make difficult clinical decisions. CONCLUSION: The case study accentuates the significance of prudent judgment in medical practice. In the case described, the consequence of trusting the written advance directive could have been fatal, but the point is general: for the purpose of achieving excellent organizational performance, it is insufficient for health workers to rely uncritically on rules and procedures. Even the clearest rule formulations must be interpreted contextually in order to determine ethically correct behavior and avoid potential negative consequences that are not in the patient's best interests.

The demented patient who declines to be dialyzed and the unhappy armed police officer son: what should be done?

Dialysis personnel are responsible for ensuring that patients' rights and physical safety are protected in dialysis centers. Treatment of patients with cognitive impairment, including patients with dementia, presents special challenges. These patients may attempt to pull out their dialysis needles during treatment, potentially endangering themselves, dialysis center personnel, and other patients. Such patients may also compromise the care of other patients in the center by upsetting them and requiring a disproportionate amount of staff attention during treatment. Dialysis centers have learned to require families of such patients to provide a sitter to ensure that the patient remains safe during the dialysis treatment; however, some patients may exhibit unsafe behaviors despite a sitter, and not all families are willing to provide a sitter. In some instances, family members respond to the stress of a loved one who is unsafe on dialysis by being verbally or physically abusive to dialysis staff. This article presents a case in which the family member was a police officer who was not only verbally and physically intimidating to the staff but also insisted on bringing his police service weapon into the dialysis center. It describes the psychosocial, ethical, and legal responses to a family member who is disrupting what should be a calm environment in the dialysis center and recommends that dialysis centers proactively develop policies concerning safety for patients, family members, and other visitors that make no exceptions. The case also highlights the importance of adopting a no weapons policy and posting and enforcing a no weapons sign.

Should paramedics ever accept patients' refusal of treatment or further assessment?

BACKGROUND: This case report discusses an ethical communication dilemma in prehospital patient interaction, involving a patient who was about to board a plane at a busy airport. The article argues that the situation raised dilemmas about communication, patient autonomy and paternalism. Paramedics should be able to find good solutions to these dilemmas, but they have not received much attention in the literature on prehospital ambulance work. CASE PRESENTATION: The patient had chest pains that were consistent with serious heart disease, but she wanted to catch her plane and was unwilling to let paramedics assess her heart activity by means of an electrocardiogram (ECG). The paramedics had to decide, there and then, whether the patient's refusal to submit to an ECG should be respected, or whether they should set the patient's expressed wishes aside by exercising verbal power and persuasive communication techniques. The paramedics chose to do the latter. It later turned out that the patient was grateful that the paramedics had been very direct, almost brutal, in their communication. When the patient regained her autonomy, she saw clearly that taking time to obtain and monitor an ECG was the best option for her. CONCLUSION: Looking forward in time might be a good professional strategy for deciding whether ethical paternalism in communication is justified. If there is good reason to believe that patients who later regain their autonomy will agree that paternalistic verbal actions were in their best interests, and if acting in accordance with patients' preferences can have severe negative health consequences for them, then paramedics have good reason to believe that ethical paternalism is justified.

The ethics of resuscitation: how do paramedics experience ethical dilemmas when faced with cancer patients with cardiac arrest?

INTRODUCTION: Research on prehospital emergency work traditionally has focused on medical issues, but paramedics often have to make ethical choices. The goal of this exploratory study was to understand how paramedics experience difficult ethical dilemmas regarding resuscitation of cancer patients. METHODS: Paramedics from ambulance services in Norway were interviewed about resuscitation of cancer patients with cardiac arrest. The qualitative study included naturalistic, semi-structured interviews and a cognitive-emotional, interpretive approach. RESULTS: All study participants believed that it ethically can be correct not to resuscitate if the patient is expected to survive for only a short time with a very low quality of life and severe negative illness experiences. However, this belief sometimes failed to match formal or informal guidelines and contextual factors such as expectations of relatives. When confronting these challenges, the majority of the paramedics relied heavily on the advice of medical experts, but some had to make more autonomous decisions. DISCUSSION: The concept of a double pressure situation can be used to analyze the ethical dilemmas regarding resuscitation of cancer patients. The pressure from "below" is grounded in individual caring frameworks, and in the belief that it can be wrong to resuscitate. The pressure from "above" is objective and system-related, related to uncertainty, and grounded in the fundamental and irreducible value of human life. CONCLUSIONS: The findings of this qualitative, exploratory study suggest that ethical concepts and analyses of double pressure situations should have an important role in education and training designed to prepare emergency personnel for difficult life and death choices. More research is needed to shed light on how ethical dilemmas arise in prehospital work.