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.

Managing ethical aspects of advance directives in emergency care services.

BACKGROUND: In Hospital Emergency Department and Emergency Medical Services professionals experience situations in which they face difficulties or barriers to know patient's advance directives and implement them. OBJECTIVES: To analyse the barriers, facilitators, and ethical conflicts perceived by health professionals derived from the management of advance directives in emergency services. RESEARCH DESIGN, PARTICIPANTS, AND CONTEXT: This is a qualitative phenomenological study conducted with purposive sampling including a population of nursing and medical professionals linked to Hospital Emergency Department and Emergency Medical Services. Three focus groups were formed, totalling 24 participants. We performed an inductive-type thematic discourse analysis. ETHICAL CONSIDERATIONS: This study was approved by ethical committees of Ethical Commitee of Clínic Hospital (Barcelona) and Comittee of Emergency Medical Services (Barcelona). The participants received information about the purpose of the study. Patients' anonymity and willingness to participate in the study were guaranteed. FINDINGS: There were four types of barriers that hindered the proper management of patients' advance directives in Hospital Emergency Department and Emergency Medical Services: personal and professional, family members, organisational and structural, and those derived from the health system. These barriers caused ethical conflicts and hindered professionals' decision-making. DISCUSSION: These results are in line with those of previous studies and indicate that factors such as gender, professional category, and years of experience, in addition to professionals' beliefs and the opinions of colleagues and family members, can also influence the professionals' final decisions. CONCLUSION: The different strategies described in this study can contribute to the development of health policies and action protocols to help reduce both the barriers that hinder the correct management and implementation of advance directives and the ethical conflicts generated.

A Primer on the Good Samaritan Act.

This article explores the various legal and ethical facets for healthcare professionals to consider in order to avoid legal liability when rendering aid in an emergency. A general overview of Good Samaritan legislation enacted throughout the United States is discussed along with varying levels of assistance required or protected by law in selected states. Moral considerations for Christian nurses are addressed.

Utilitarianism and the pandemic.

There are no egalitarians in a pandemic. The scale of the challenge for health systems and public policy means that there is an ineluctable need to prioritize the needs of the many. It is impossible to treat all citizens equally, and a failure to carefully consider the consequences of actions could lead to massive preventable loss of life. In a pandemic there is a strong ethical need to consider how to do most good overall. Utilitarianism is an influential moral theory that states that the right action is the action that is expected to produce the greatest good. It offers clear operationalizable principles. In this paper we provide a summary of how utilitarianism could inform two challenging questions that have been important in the early phase of the pandemic: (a) Triage: which patients should receive access to a ventilator if there is overwhelming demand outstripping supply? (b) Lockdown: how should countries decide when to implement stringent social restrictions, balancing preventing deaths from COVID-19 with causing deaths and reductions in well-being from other causes? Our aim is not to argue that utilitarianism is the only relevant ethical theory, or in favour of a purely utilitarian approach. However, clearly considering which options will do the most good overall will help societies identify and consider the necessary cost of other values. Societies may choose either to embrace or not to embrace the utilitarian course, but with a clear understanding of the values involved and the price they are willing to pay.

Obstetric hospital preparedness for a pandemic: an obstetric critical care perspective in response to COVID-19.

The Coronavirus disease 2019 (COVID-19) caused by Severe Acute Respiratory Syndrome Coronavirus-2 (SARS-CoV-2) pandemic has had a rapid and deadly onset, spreading quickly throughout the world. Pregnant patients have had high mortality rates, perinatal losses, and Intensive Care Unit (ICU) admissions from acute respiratory syndrome Coronavirus (SARS-CoV) and Middle East respiratory syndrome Coronavirus (MERS-CoV) in the past. Potentially, a surge of patients may require hospitalization and ICU care beyond the capacity of the health care system. This article is to provide institutional guidance on how to prepare an obstetric hospital service for a pandemic, mass casualty, or natural disaster by identifying a care model and resources for a large surge of critically ill pregnant patients over a short time. We recommend a series of protocols, education, and simulation training, with a structured and tiered approach to match the needs for the patients, for hospitals specialized in obstetrics.

Patient and surrogate attitudes via an interviewer-administered survey on exception from informed consent enrollment in the Prehospital Air Medical Plasma (PAMPer) trial.

OBJECTIVES: With increased focus on early resuscitation methods following injury to improve patient outcomes, studies are employing exception from informed consent (EFIC) enrollment. Few studies have assessed patients' opinions following participation in an EFIC study, and none have been conducted within the realm of traumatic hemorrhage. We surveyed those patients and surrogates previously enrolled in the Prehospital Air Medical Plasma (PAMPer) Trial to clarify their opinions related to consent and emergency research. METHODS: Telephone calls were made between January-June 2019 to all patients who were enrolled under EFIC in the PAMPer study at the Pittsburgh site (169 of the 501 total patients enrolled, May 2014-Oct 2017) and their surrogates. Questions gauging approval of EFIC enrollment were asked before discussion of PAMPer trial outcomes, after disclosure of positive outcomes, and after a hypothetical negative trial outcome was proposed. RESULTS: Of the total 647 telephone calls made, ninety-three interviews, reflecting 70 of 169 patient enrollments, were conducted. This included 13 in which only the patient was interviewed, 23 in which the patient and a surrogate were interviewed, and 34 in which only a surrogate was interviewed. Nearly half (48.4%) of respondents did not recall their personal or family member enrollment in the study. No patients or surrogates recalled hearing about the study through community consultation or being aware of opt out procedures. Patients and surrogates were glad they were enrolled (90.3%), agreed with EFIC use for their personal enrollment (88.17%), and agreed with the general use of EFIC for the PAMPer study (81.7%). Disclosure of the true positive PAMPer study outcome resulted in a significant increase in opinions regarding personal enrollment, EFIC for personal enrollment, and EFIC for general enrollment (all p < 0.001). Disclosure of a hypothetical neutral or negative study outcome resulted in significant decreases in opinions regarding EFIC for personal enrollment (p = 0.003) and EFIC for general enrollment (p < 0.001). CONCLUSIONS: Clinical trial participants with traumatic hemorrhagic shock enrolled with EFIC, and surrogates of such participants, are generally accepting of EFIC. The results of the trial in which EFIC was utilized significantly affected patient and surrogate agreement with personal and general EFIC enrollment.

Patient's informational privacy in prehospital emergency care: Paramedics' perspective.

BACKGROUND: As a fundamental human right in healthcare, informational privacy creates the foundation for patient's safety and the quality of care. However, its realization can be a challenge in prehospital emergency care, considering the nature of the work. OBJECTIVES: To describe patient's informational privacy, its realization, and the factors related to the realization in prehospital emergency care from the perspective of paramedics. RESEARCH DESIGN: A descriptive questionnaire study was conducted. The data were analyzed with inductive content analysis. PARTICIPANTS AND RESEARCH CONTEXT: The participants (n = 26) were paramedics in one of the 22 rescue departments in Finland. ETHICAL CONSIDERATIONS: The study received ethical approval from the ethics committee of the University of Turku (Finland). Permission for the study was given by the collaborating rescue department. FINDINGS: Paramedics described patient's informational privacy as patients' right to their own health records, as protection of the patient's health records, and as comprehensive respect of the patient's privacy by the persons involved in the patient's care. In general, informational privacy was described as being realized regarding confidentiality, reporting, and maintaining the patient's health records. However, it was also described as being dependent on the context, and some areas in need of improvement were identified. Promoting and preventing factors related to the realization were also identified. The promoting factors were paramedics' professional activity, environment, training, and guidelines. The preventing factors were the nature of the work, paramedics' attitudes, and the lack of knowledge concerning informational privacy among paramedics, the collaborating authority, patients, and relatives. DISCUSSION AND CONCLUSION: Paramedics had a multidimensional understanding of informational privacy and the factors related to its realization. However, its realization varies, and more research and education are therefore needed to enhance the realization and to provide equal and high-quality care for all the patients in prehospital emergency care.

Ethical conflicts in patient relationships: Experiences of ambulance nursing students.

BACKGROUND: Working as an ambulance nurse involves facing ethically problematic situations with multi-dimensional suffering, requiring the ability to create a trustful relationship. This entails a need to be clinically trained in order to identify ethical conflicts. AIM: To describe ethical conflicts in patient relationships as experienced by ambulance nursing students during clinical studies. RESEARCH DESIGN: An exploratory and interpretative design was used to inductively analyse textual data from examinations in clinical placement courses. PARTICIPANTS: The 69 participants attended a 1-year educational programme for ambulance nurses at a Swedish university. ETHICAL CONSIDERATIONS: The research was conducted in accordance with the Declaration of Helsinki. Participants gave voluntary informed consent for this study. FINDINGS: The students encountered ethical conflicts in patient relationships when they had inadequate access to the patient's narrative. Doubts regarding patient autonomy were due to uncertainty regarding the patient's decision-making ability, which forced students to handle patient autonomy. Conflicting assessments of the patient's best interest added to the conflicts and also meant a disruption in patient focus. The absence of trustful relationships reinforced the ethical conflicts, together with an inadequacy in meeting different needs, which limited the possibility of providing proper care. DISCUSSION: Contextual circumstances add complexity to ethical conflicts regarding patient autonomy, dependency and the patient's best interest. Students felt they were fluctuating between paternalism and letting the patient choose, and were challenged by considerations regarding the patient's communication and decision-making ability, the views of third parties, and the need for prioritisation. CONCLUSION: The essence of the patient relationship is a struggle to preserve autonomy while focusing on the patient's best interest. Hence, there is a need for education and training that promotes ethical knowledge and ethical reflection focusing on the core nursing and caring values of trust and autonomy, particularly in situations that affect the patient's decision-making ability.

Subsequent Consent and Blameworthiness.

Informed consent is normally understood as something that a patient gives prior to a medical intervention that can render it morally permissible. Whether or not it must be given prior to the intervention is debated. Some have argued that subsequent consent-that is, consent given after a medical intervention-can also render an otherwise impermissible act permissible. If so, then a patient may give her consent to an intervention that has already been performed and thereby justify a physician's (paternalistic) act retroactively. The purpose of this paper is to argue that even if subsequent consent can render an otherwise impermissible act permissible, doctors are still blameworthy if they rely on it when prior consent could be given, because they would be banking on the justification of their interventions. Since doctors can only guess if patients will consent after the fact, they would be placing their patients at unreasonable risk of being disrespected as persons.

Uninformed refusals: objections to enrolment in clinical trials conducted under an Exception from Informed Consent for emergency research.

Clinical trials in emergency situations present unique challenges, because they involve enrolling individuals who lack capacity to consent in the context of acute illness or injury. The US Department of Health and Human Services and Food and Drug Administration regulations allowing an Exception from Informed Consent (EFIC) in these circumstances contain requirements for community consultation, public disclosure and restrictions on study risks and benefits. In this paper, we analyse an issue raised in the regulations that has received little attention or analysis but is ethically complex. This challenge is when to solicit and honour objections to EFIC trial enrolment, including from non-legally appointed representatives. We address novel questions involving whose objections should be honoured, what level of understanding is necessary for objections to be considered valid and how hard investigators should work to offer an opportunity to object. We present a set of criteria that provide conceptual and practical guidance. We argue that objections should be honoured if they undermine one of the key assumptions that allows for the permissibility of EFIC trials: that individuals would likely not object to enrolment based on their values or preferences. We then clarify the practical implications of this approach through examination of three cases of refusal in an EFIC study.

The ethical justification for inclusion of neonates in pragmatic randomized clinical trials for emergency newborn care.

BACKGROUND: Research guidelines generally recognize vulnerable populations to include neonates with the aim of enhancing protections from harm. In practice, such guidance results in limiting participation in randomized clinical trials (RCTs). Yet while medical care of neonates should be based on best research evidence to ensure that safe, efficacious treatment or procedures are used, this seldom happens in contemporary practice. DISCUSSION: The compelling need to generate information on effectiveness and safety of procedures and medications that are already in use during neonatal care has led to increase in calls for pragmatic randomized clinical trials (PCTs). This raises ethical concerns as to whether exclusion of the vulnerable populations from research participations constitutes harm. First, neonates are denied access to both potentially beneficial research outputs and an opportunity to generate data on how interventions or medications perform in diverse clinical settings and inform clinical decision-making. Secondly, risks and harms in PCTs may differ from traditional RCTs, and can be reduced by modifications in study designs. The latter may involve assessment of effectiveness of comparable medication, devices or practices (whose safety data is available), randomization at the group level rather than at the individual level, avoidance of invasive and innovative study procedures, reliance on locally available data on relevant patient outcomes, and employment of procedures that tend to meet the criteria of minimal risk for human subject research. Thirdly, informed consent procedures should be modified from those of traditional RCTs, as neonates in traditional RCTs may be vulnerable to different extents in PCTs. Lastly, regulatory and oversight procedures designed for traditional RCT settings need modification, as they may not be translatable, feasible, appropriate or even ethical to apply in PCTs. CONCLUSION: The principle of justice, commonly interpreted as preventing an inequitable burden of research, should also allow fair access to potential benefits from PCTs for neonates and other vulnerable populations. Under certain conditions, prospective randomized trials involving neonates should be ethically permissible to allow inclusion of neonates in research. This may require modification of the research design, consent procedures or regulations for research oversight.

Ethical tensions in the informed consent process for randomized clinical trials in emergency obstetric and newborn care in low and middle-income countries.

BACKGROUND: There is unanimous agreement regarding the need to ethically conduct research for improving therapy for patients admitted to hospital with acute conditions, including in emergency obstetric care. We present a conceptual analysis of ethical tensions inherent in the informed consent process for randomized clinical trials for emergency obstetric care and suggest ways in which these could be mitigated. DISCUSSION: A valid consenting process, leading to an informed consent, is a cornerstone of this aspect necessary for preservation and maintenance of respect for autonomy and dignity. In emergency obstetric care research, obtaining informed consent can be problematic, leading to ethical tension between different moral considerations. Potential participants may be vulnerable due to severity of disease, powerlessness or impaired decisional capacity. Time for the consent process is limited, and some interventions have a narrow therapeutic window. These factors create ethical tension in allowing potentially beneficial research while avoiding potential harms and maintaining respect for dignity, human rights, justice and autonomy of the participants. CONCLUSION: Informed consent in emergency obstetric care in low- and middle-income countries poses numerous ethical challenges. Allowing research on vulnerable populations while maintaining respect for participant dignity and autonomy, protecting participants from potential harms and promoting justice underlie the ethical tensions in the research in emergency obstetric and newborn care. Those involved in research conduct or oversight have a duty of fair inclusion, to avoid denying participants the right to participate and to any potential research benefits.

Ethical considerations in prehospital ambulance based research: qualitative interview study of expert informants.

BACKGROUND: Prehospital ambulance based research has unique ethical considerations due to urgency, time limitations and the locations involved. We sought to explore these issues through interviews with experts in this research field. METHODS: We undertook semi-structured interviews with expert informants, primarily based in the UK, seeking their views and experiences of ethics in ambulance based clinical research. Participants were questioned regarding their experiences of ambulance based research, their opinions on current regulations and guidelines, and views about their general ethical considerations. Participants were chosen because they were actively involved in, or in their expert capacity (e.g. law) expressed an interest in, ambulance based research. RESULTS: Fourteen participants were interviewed including principal investigators, researchers, ethicists and medical lawyers. Five major themes were identified: Capacity, Consent, Clinical Considerations, Consultation and Regulation. Questions regarding consent and capacity were foremost in the discussions as all participants highlighted these as areas for concern. The challenges and use of multiple consent models reflected the complexity of research in this environment. The clinical theme referred to the role of paramedics in research and how research involving ambulance services is increasingly informing improvements to patient care and outcomes and reducing the burden on hospital services. Most felt that, although current regulations were fit for purpose, more specific guidance on implementing these in the ambulance setting would be beneficial. This related closely to the theme of consultation, which examined the key role of ethics committees and other regulatory bodies, as well as public engagement. CONCLUSIONS: By interviewing experts in research or ethics in this setting we were able to identify key concerns and highlight areas for future development such as improved guidance.

Ethical dilemmas during cardiac arrest incidents in the patient's home.

BACKGROUND:: The majority (70%) of cardiac arrests in Sweden are experienced in the patient's home. In these situations, the ambulance nurses may encounter several ethical dilemmas. AIM:: The aim was to investigate Swedish specialist ambulance nurses' experiences of ethical dilemmas associated with cardiac arrest situations in adult patients' homes. METHODS:: Nine interviews were conducted with specialist ambulance nurses at four different ambulance stations in the southeast region of Sweden. Data were analysed using content analysis. ETHICAL CONSIDERATIONS:: Ethical principles mandated by the Swedish Research Council were carefully followed during the whole process. FINDINGS:: Two main themes with six sub-themes were identified: The scene - creating a sheltered space for caring and Ethical decision-making. The results showed that ethical dilemmas might occur when trying to create a sheltered space to preserve the patients' integrity and dignity. A dilemma could be whether or not to invite significant others to be present during the medical treatment. Ethical decision-making was dependent on good communication and ethical reasoning among all parties. In certain situations, decisions were made not to commence or to terminate care despite guidelines. The decision was guided by combining the medical/nursing perspectives and ethical competence with respect to the human being's dignity and a will to do good for the patient. The nurses followed the voice of their heart and had the courage to be truly human. CONCLUSION:: The ambulance nurses were guided by their ethos, including the basic motive to care for the patient, to alleviate suffering, to confirm the patient's dignity and to serve life and health.

Ethical decision-making based on field assessment: The experiences of prehospital personnel.

INTRODUCTION: Due to the stressful nature of prehospital emergency providers' duties, as well as difficulties such as distance to information resources and insufficient time to analyze situations, ethical decision-making in prehospital services is a daily challenge. OBJECTIVES: This study aimed to describe the experiences of Iranian prehospital emergency personnel in the field of ethical decision-making. METHODS: The data were collected by semi-structured interviews (n = 15) in Iran and analyzed using the content analysis approach. ETHICAL CONSIDERATIONS: This study was conducted in accordance with the principles of research ethics and national rules and regulations relating to informed consent and confidentiality. RESULTS: The results obtained were categorized into three main categories that included "assessment of the scene atmosphere, assessment of patients' condition and their family, and predicting outcomes of decision-making." The central category was "field assessment," which demonstrated the strategy of ethical decision-making by prehospital providers when facing ethical conflicts. CONCLUSION: Although findings showed that the majority of prehospital providers make ethical decisions based on the patients' benefit, they also consider consequences of their decisions in dealing with personal and professional threats. This article identifies and describes a number of ethical values of prehospital providers and discusses how the values may be considered by paramedics when facing ethical conflicts.

Ethics of Outbreaks Position Statement. Part 1: Therapies, Treatment Limitations, and Duty to Treat.

OBJECTIVES: Outbreaks of disease, especially those that are declared a Public Health Emergency of International Concern, present substantial ethical challenges. Here we start a discourse (with a continuation of the dialogue in Ethics of Outbreaks Position Statement. Part 2: Family-Centered Care) concerning the ethics of the provision of medical care, research challenges and behaviors during a Public Health Emergency of International Concern with a focus on the proper conduct of clinical or epidemiologic research, clinical trial designs, unregistered medical interventions (including vaccine introduction, devices, pharmaceuticals, who gets treated, vulnerable populations, and methods of data collection), economic losses, and whether there is a duty of health care providers to provide care in such emergencies, and highlighting the need to understand cultural diversity and local communities in these efforts. DESIGN: Development of a Society of Critical Care Medicine position statement using literature review and expert consensus from the Society of Critical Care Medicine Ethics committee. The committee had representation from ethics, medical philosophy, critical care, nursing, internal medicine, emergency medicine, pediatrics, anesthesiology, surgery, and members with international health and military experience. SETTING: Provision of therapies for patients who are critically ill or who have the potential of becoming critically ill, and their families, regarding medical therapies and the extent of treatments. POPULATION: Critically ill patients and their families affected by a Public Health Emergency of International Concern that need provision of medical therapies. INTERVENTIONS: Not applicable. MAIN RESULTS: Interventions by high income countries in a Public Health Emergency of International Concern must always be cognizant of avoiding a paternalistic stance and must understand how families and communities are structured and the regional/local traditions that affect public discourse. Additionally, the obligations, or the lack of obligations, of healthcare providers regarding the treatment of affected individuals and communities must also be acknowledged. Herein, we review such matters and suggest recommendations regarding the ethics of engagement in an outbreak that is a Public Health Emergency of International Concern.

Ethics of Outbreaks Position Statement. Part 2: Family-Centered Care.

OBJECTIVES: Continue the dialogue presented in Ethics of Outbreaks Position Statement. Part 1, with a focus on strategies for provision of family-centered care in critical illness during Pubic Health Emergency of International Concern. DESIGN: Development of a Society of Critical Care Medicine position statement using literature review, expert consensus from the Society of Critical Care Medicine Ethics Committee. A family member of a patient who was critically ill during a natural disaster served on the writing panel and provided validation from a family perspective to the recommendations. SETTING: Provision of family-centered care and support for patients who are critically ill or who have the potential of becoming critically ill, and their families, during a Pubic Health Emergency of International Concern. INTERVENTIONS: Communication; family support. MEASUREMENTS AND MAIN RESULTS: Family-centered interventions during a Pubic Health Emergency of International Concern include understanding how crisis standards may affect regional and local traditions. Transparently communicate changes in decision-making authority and uncertainty regarding treatments and outcomes to the family and community. Assess family coping, increase family communication and support, and guide families regarding possible engagement strategies during crisis. Prepare the public to accept survivors returning to the community.

A comprehensive systematic review of stakeholder attitudes to alternatives to prospective informed consent in paediatric acute care research.

BACKGROUND: A challenge of performing research in the paediatric emergency and acute care setting is obtaining valid prospective informed consent from parents. The ethical issues are complex, and it is important to consider the perspective of participants, health care workers and researchers on research without prospective informed consent while planning this type of research. METHODS: We performed a systematic review according to PRISMA guidelines, of empirical evidence relating to the process, experiences and acceptability of alternatives to prospective informed consent, in the paediatric emergency or acute care setting. Major medical databases and grey sources were searched and results were screened and assessed against eligibility criteria by 2 authors, and full text articles of relevant studies obtained. Data were extracted onto data collection forms and imported into data management software for analysis. RESULTS: Thirteen studies were included in the review consisting of nine full text articles and four abstracts. Given the heterogeneity of the methods, results could not be quantitatively combined for meta-analysis, and qualitative results are presented in narrative form, according to themes identified from the data. Major themes include capacity of parents to provide informed consent, feasibility of informed consent, support for alternatives to informed consent, process issues, modified consent process, child death, and community consultation. CONCLUSION: Our review demonstrated that children, their families, and health care staff recognise the requirement for research without prior consent, and are generally supportive of enrolling children in such research with the provisions of limiting risk, and informing parents as soon as possible. Australian data and perspectives of children are lacking and represent important knowledge gaps.

Experiences of pre-hospital emergency medical personnel in ethical decision-making: a qualitative study.

BACKGROUND: Emergency care providers regularly deal with ethical dilemmas that must be addressed. In comparison with in-hospital nurses, emergency medical service (EMS) personnel are faced with more problems such as distance to resources including personnel, medico-technical aids, and information; the unpredictable atmosphere at the scene; arriving at the crime scene and providing emergency care for accident victims and patients at home. As a result of stressfulness, unpredictability, and often the life threatening nature of tasks that ambulance professionals have to deal with every day, ethical decision-making (EDM) has become an inevitable challenge. METHODS: The content analysis approach was used to conduct the present qualitative study in Iran. The participants consisted of 14 EMS personnel selected through purposive sampling, which continued until the data became saturated. Data were collected using semi-structured interviews and analyzed concurrently with their collection through the constant comparison method. RESULTS: The process of data analysis resulted in the emergence of 3 main categories "respecting client's values", "performing tasks within the professional manner", "personal characteristic", and the emergence of eight (8) sub-categories signifying participants' experiences with regard to EDM. CONCLUSION: According to the results, when EMS personnel are faced with ethical dilemmas, they consider the client's values and professional dignity, and perform the assigned tasks within the framework of the regulation. The findings also suggest that pre-hospital care providers assess legal consequences before making any decision. Further studies should be conducted regarding the experiences of the subordinates and other related parties.