Capacity Assessment in Emergency Surgery.

AbstractInformed consent is a necessary component of the ethical practice of surgery. Ideally, consent is performed in a setting conducive to a robust patient-provider conversation, with careful consideration of risks, benefits, and outcomes. For patients with medical or surgical emergencies, navigating the consent process can be complicated and requires both careful and expedited assessment of decision-making capacity. We present a recent case in which a patient in need of emergency care refused intervention, requiring urgent capacity assessment and a modification to usual care.

Do COVID-19 patients needing extended care in an intensive care unit fall under the 'emergency medical treatment' provisions of the South African Constitution?

Whether COVID-19 patients in need of extended care in an intensive care unit qualify for 'emergency medical treatment' is answered by considering the Constitution, the meaning of emergency medical treatment, and whether such patients are in an incurable chronic condition. Considering ethical guidelines for the withholding and withdrawal of treatment may assist a court in determining whether a healthcare practitioner has acted with the degree of skill and care required of a reasonably competent practitioner in his or her branch of the profession.

Beliefs and challenges held by medical staff about providing emergency care to migrants: an international systematic review and translation of findings to the UK context.

OBJECTIVE: Migration has increased globally. Emergency departments (EDs) may be the first and only contact some migrants have with healthcare. Emergency care providers' (ECPs) views concerning migrant patients were examined to identify potential health disparities and enable recommendations for ED policy and practice. DESIGN: Systematic review and meta-synthesis of published findings from qualitative studies. DATA SOURCES: Electronic databases (Ovid Medline, Embase (via Ovid), PsycINFO (via OVID), CINAHL, Web of Science and PubMed), specialist websites and journals were searched. ELIGIBILITY CRITERIA: Studies employing qualitative methods published in English. SETTINGS: EDs in high-income countries. PARTICIPANTS: ECPs included doctors, nurses and paramedics. TOPIC OF ENQUIRY: Staff views on migrant care in ED settings. DATA EXTRACTION AND SYNTHESIS: Data that fit the overarching themes of 'beliefs' and 'challenges' were extracted and coded into an evolving framework. Lines of argument were drawn from the main themes identified in order to infer implications for UK policy and practice. RESULTS: Eleven qualitative studies from Europe and the USA were included. Three analytical themes were found: challenges in cultural competence; weak system organisation that did not sufficiently support emergency care delivery; and ethical dilemmas over decisions on the rationing of healthcare and reporting of undocumented migrants. CONCLUSION: ECPs made cultural and organisational adjustments for migrant patients, however, willingness was dependent on the individual's clinical autonomy. ECPs did not allow legal status to obstruct delivery of emergency care to migrant patients. Reported decisions to inform the authorities were mixed; potentially leading to uncertainty of outcome for undocumented migrants and deterring those in need of healthcare from seeking treatment. If a charging policy for emergency care in the UK was introduced, it is possible that ECPs would resist this through fears of widening healthcare disparities. Further recommendations for service delivery involve training and organisational support.

Emergency care in rural settings: Can doctors be ethical and survive?

We describe below the pressures of running a small private hospital in an underserved rural area, while providing emergency healthcare for victims of poisonous stings, accidents, and other acute health conditions. Both ethics and law demand that payment is not asked for upfront in emergency cases. Yet patients and their families often fail to pay normal dues for months or even years. It is disturbing to encounter such behaviour even in villages; and doctors in small communities are easy prey. In these conditions can one be true to ethical principles and ensure one's own survival?

Ethics, health policy, and Zika: From emergency to global epidemic?

Zika virus was recognised in 2016 as an important vector-borne cause of congenital malformations and Guillain-Barré syndrome, during a major epidemic in Latin America, centred in Northeastern Brazil. The WHO and Pan American Health Organisation (PAHO), with partner agencies, initiated a coordinated global response including public health intervention and urgent scientific research, as well as ethical analysis as a vital element of policy design. In this paper, we summarise the major ethical issues raised during the Zika epidemic, highlighting the PAHO ethics guidance and the role of ethics in emergency responses, before turning to ethical issues that are yet to be resolved. Zika raises traditional bioethical issues related to reproduction, prenatal diagnosis of serious malformations and unjust disparities in health outcomes. But the epidemic has also highlighted important issues of growing interest in public health ethics, such as the international spread of infectious disease; the central importance of reproductive healthcare in preventing maternal and neonatal morbidity and mortality; diagnostic and reporting biases; vector control and the links between vectors, climate change, and disparities in the global burden of disease. Finally, there are controversies regarding Zika vaccine research and eventual deployment. Zika virus was a neglected disease for over 50 years before the outbreak in Brazil. As it continues to spread, public health agencies should promote gender equity and disease control efforts in Latin America, while preparing for the possibility of a global epidemic.

Cops and docs: The challenges for ED physicians balancing the police, state laws, and EMTALA.

State laws are awash with discord concerning whether a police officer's request or court order necessarily obligates physicians to perform a body fluid analysis of an arrested, conscious, nonconsenting suspect. Police typically bring arrestees directly to the emergency department (ED), and federal courts have begun to wrestle with the implications of the Emergency Medical Treatment and Labor Act (EMTALA), which requires that anyone presenting to the ED be screened for treatment. Some state laws require health care providers to comply with any police request for lab analysis, while other states offer more leeway to physicians. Recent trends in federal case law interpreting EMTALA suggest that a medical screening exam is not required for patients brought by police specifically for a blood or urine sample unless either the arrestee requests medical care or a prudent observer would believe medical care was indicated. This article answers two questions: What happens when a police officer presents to the ED requesting service on behalf of an arrestee? What does EMTLA require of physicians in response? We survey current state statutes, review recent state and federal case law, describe example policies from various hospitals, and conclude with recommendations for hospital risk managers.

Observation Care: Ethical and Legal Considerations for the Emergency Physician.

BACKGROUND: The Medicare observation rules remain controversial despite Centers for Medicare and Medicaid Services revisions and the new 2-midnight rule. The increased financial risks for patients and heightened awareness of the rule have placed emergency physicians (EPs) at the center of the controversy. DISCUSSION: This article reviews the primary ethical and legal (particularly with respect to the Emergency Medical Treatment and Active Labor Act) implications of the existing observation rule for EPs and offers practical solutions for EPs faced with counseling patients on the meaning and ramifications of the observation rule. CONCLUSIONS: We conclude that while we believe it does not violate the intent of the Emergency Medical Treatment and Active Labor Act to respond to patient questions about their admission status, the observation rules challenge the ethical principles of transparency related to the physician-patient relationship and justice as fairness. Guidance for physicians is offered to improve transparency and patient fairness.

Emergency general surgery in the geriatric patient.

BACKGROUND: Emergency general surgery in the elderly is a particular challenge to the surgeon in charge of their care. The aim was to review contemporary aspects of managing elderly patients needing emergency general surgery and possible alterations to their pathways of care. METHODS: This was a narrative review based on a PubMed/MEDLINE literature search up until 15 September 2015 for publications relevant to emergency general surgery in the geriatric patient. RESULTS: The number of patients presenting as an emergency with a general surgical condition increases with age. Up to one-quarter of all emergency admissions to hospital may be for general surgical conditions. Elderly patients are a particular challenge owing to added co-morbidity, use of drugs and risk of poor outcome. Frailty is an important potential risk factor, but difficult to monitor or manage in the emergency setting. Risk scores are not available universally. Outcomes are usually severalfold worse than after elective surgery, in terms of both higher morbidity and increased mortality. A care bundle including early diagnosis, resuscitation and organ system monitoring may benefit the elderly in particular. Communication with the patient and relatives throughout the care pathway is essential, as indications for surgery, level of care and likely outcomes may evolve. Ethical issues should also be addressed at every step on the pathway of care. CONCLUSION: Emergency general surgery in the geriatric patient needs a tailored approach to improve outcomes and avoid futile care. Although some high-quality studies exist in related fields, the overall evidence base informing perioperative acute care for the elderly remains limited.

Ethical issues in the care of persons living with haemophilia in India.

The recent series of ad interim orders issued by the Bombay High Court under ordinary original civil jurisdiction following public interest litigation (PIL) on the provision of free clotting factor concentrates for persons living with haemophilia, especially those below the poverty line and emergency cases, highlights the need to think about the ethicality of various aspects of access to medicine and the rights of patients suffering from rare diseases from the public health perspective. The PIL (number 82/2012) [Vinay Vijay Nair and Ors vs. Department of Health, State of Maharashtra and Ors), which calls for free treatment for all haemophiliacs who go to the designated hospitals, was followed by the issuance of five ad interim orders (July 19, 2012, October 22, 2012, November 6, 2012, January 24, 2013, and March 19, 2013).

Refusal of emergency caesarean section in Ireland: a relational approach.

This article examines the issue of emergency caesarean section refusal. This raises complex legal and ethical issues surrounding autonomy, capacity, and the right to refuse treatment. In Ireland, the situation is complicated further by the constitutional right to life of the unborn. While cases involving caesarean section refusal have occurred in other jurisdictions, a case of this nature has yet to be reported in Ireland. This article examines possible ways in which the interaction of a woman's right to refuse treatment and the right to life of the unborn could be approached in Ireland in the context of caesarean section refusal. The central argument of the article is that the liberal individualistic approach to autonomy evident in the caesarean section cases in England and Wales is difficult to apply in the Irish context, due to the conflicting constitutional rights of the woman and foetus. Thus, alternative visions of autonomy which take the interests and rights of others into account in medical decision-making are examined. In particular, this article focuses on the concept of relational consent, as developed by Alasdair Maclean and examines how such an approach could be applied in the context of caesarean section refusal in Ireland. The article explains why this approach is particularly appropriate and identifies mechanisms through which such a theory of consent could be applied. It is argued that this approach enhances a woman's right to autonomy, while at the same time allows the right to life of the unborn to be defended.

O uso do termo de consentimento livre e esclarecido na prática médica / The use of the free and clarified consent term in medical practice

Este artigo analisa a aplicação do termo de consentimento livre e esclarecido (TCLE) na prática dos médicos que trabalham no Hospital Universitário (HU) da Universidade Federal de Sergipe, localizado na cidade de Aracaju. A pesquisa que originou o trabalho verificou aatribuição de importância à aplicação do TCLE na prática médica. Foram entrevistados cinco médicos do HU, bem como analisados 72 prontuários de pacientes internos, de acordo com a bioética, a legislação e a doutrina brasileiras. Concluiu-se que apesar de visto como importante, o TCLE só é utilizado em dois serviços naquela unidade, apesar dos avanços da responsabilidade civil médica no Brasil.

An open letter to institutional review boards considering Northfield Laboratories' PolyHeme® trial.

At the time of this writing, a widely publicized, waived-consent trial is underway. Sponsored by Northfield Laboratories, Inc. (Evanston, IL) the trial is intended to evaluate the emergency use of PolyHeme®, an oxygen-carrying resuscitative fluid that might prevent deaths from uncontrolled bleeding. The protocol allows patients in hemorrhagic shock to be randomized between PolyHeme® and saline in the field and, still without consent, randomized between PolyHeme® and blood after arrival at an emergency department. The Federal regulations that govern the waiver of consent restrict its applicability to circumstances where proven, satisfactory treatments are unavailable. Blood-the standard treatment for hemorrhagic shock-is not available in ambulances but is available in hospitals. The authors argue that the in-hospital stage of the study fails to meet ethical and regulatory standards.

Bedside ethics and health system catastrophe: imagine if you will...

Preparations for large-scale disasters have tended to focus on triage schema, stockpiling of materials, and other logistical concerns. Less attention has been given to the myriad of distressing and almost unthinkable ethically charged dilemmas that will emerge at the bedside during a catastrophe, and how they may be best managed. Yet, it is these bedside issues that may limit or thwart the effectiveness of disaster planning, and, therefore, they ought to be carefully considered.

Should palliative care be a necessity or a luxury during an overwhelming health catastrophe?

In the event of a widespread health catastrophe in which either or both human and material resources were in critically short supply, rationing must take place, especially if the scarcity will last for some time. There are several tested allocation methods that are routinely used during emergencies. These include triage procedures employed by emergency departments and the military on the battlefield. The goal is to save the lives of as many as possible. When it is not possible to save all, or even most, who come for care, what should be done, if anything, with those whose fate is death? The central tenet and goal of medicine is the relief of suffering. If we take this seriously as an axiom of practice, then healthcare providers and the institutions in which they work are duty-bound to provide comfort and relief to all, especially the dying. There are several ways this can be done. One is to prepare by training sufficient individuals to provide what might be called emergency palliative care. These people do not all have to be doctors but could (and should) include people from a range of backgrounds including nursing, allied health, pastoral care, and social work. For them to be able to do their jobs effectively, some basic supplies should be stockpiled so the pain and suffering associated with untreated illness and injury can be relieved. However, what happens when there is a shortage of, say, opiates, so that relief of air hunger and pain cannot be eased? Then critical decisions must be made. Alternative sources of symptom relief not considered under ordinary circumstances might be used. However, it is possible to imagine a situation when all resources are in critically short supply. Those remaining resources, logically and morally, should be allocated to persons who can survive. In this scenario, what can be offered to the suffering dying? This might depend on the attitude of personnel caring for patients. In desperate circumstances, it is possible the proscription against active euthanasia could be justifiably overridden by concern for ongoing, relentless, and unmitigated suffering. Any justification that could be made for such action would be undermined by arbitrary or capricious administration. Thus, preparation for a catastrophic healthcare emergency should take into account all conceivable outcomes.

Emergency research: only possible if consent is waived?

PURPOSE OF THE REVIEW: Emergency research is possible only if informed consent is waived. Recent legislations have specifically addressed this issue, both in the US and in Europe. RECENT FINDINGS: In the US, a specific regulation was enacted in 1996. Due to the added complexity, few trials have used this design. The necessity to inform the community in which a trial is supposed to take place, though feasible, is burdensome and time consuming. In the EU, directive 2001/20/CE forgot to specify particular rules for research in emergency conditions. After 2004, national legislations were supposed to implement the directive in order to enhance homogeneity within Europe, but actually showed an extreme diversity, with some countries allowing waiver of consent in emergency situations and others refusing it. SUMMARY: Due to the active lobbying of emergency and intensive care specialists, the situation is slowly improving, with most national legislations recognizing the specificities and difficulty of emergency research.