Emergency Physicians' Ethical Issues with Hospital Business Models.

BACKGROUND: The changing hospital business model has raised ethical issues for emergency physicians (EPs) in a healthcare system that often prioritizes profits over patient welfare. For-profit hospitals, driven by profit motives, may prioritize treating patients with lucrative insurance plans and those who can afford expensive treatments. Private equity investors, who now own many for-profit hospitals, focus on short-term financial gains, leading to cost-cutting measures and pressure on EPs to prioritize financial goals over patient welfare. Nonprofit hospitals, mandated to provide charity care to the underserved, may fail to meet their community service obligations, resulting in disparities in healthcare access. OBJECTIVE: This review examines the ethical challenges faced by emergency physicians (EPs) in response to the evolving hospital business model, which increasingly prioritizes profits over patient welfare. DISCUSSION: Emergency physicians face ethical dilemmas in this changing environment, including conflicts between patient care and financial interests. Upholding professional ethics and the principle of beneficence is essential. Another challenge is equitable access to healthcare, with some nonprofit hospitals reducing charity care, thus exacerbating disparities. EPs must uphold the ethical principle of justice, ensuring quality care for all patients, regardless of financial means. Conflicts of interest may arise when EPs work in hospitals owned by private equity firms or with affiliations with pharmaceutical companies or medical device manufacturers, potentially compromising patient care. CONCLUSION: Emergency physicians must navigate these ethical issues while upholding professional ethics and advocating for patients' best interests. Collaboration with hospital administrators, policymakers, and stakeholders is vital to address these concerns and prioritize patient welfare in healthcare delivery.

Radiation in an emergency situation: attempting to respect the patient's beliefs as reported by a minor.

BACKGROUND: Each individual's unique health-related beliefs can greatly impact the patient-clinician relationship. When there is a conflict between the patient's preferences and recommended medical care, it can create a serious ethical dilemma, especially in an emergency setting, and dramatically alter this important relationship. CASE PRESENTATION: A 56-year-old man, who remained comatose after out-of-hospital cardiac arrest, was rushed to our hospital. The patient was scheduled for emergency coronary angiography when his adolescent daughter reported that she and her father held sincere beliefs against radiation exposure. We were concerned that she did not fully understand the potential consequences if her father did not receive the recommended treatment. A physician provided her with in depth information regarding the risks and benefits of the treatment. While we did not want to disregard her statement, we opted to save the patient's life due to concerns about the validity of her report. CONCLUSIONS: Variations in beliefs regarding medical care force clinicians to incorporate patient beliefs into medical practice. However, an emergency may require a completely different approach. When faced with a patient in a life-threatening condition and unconscious, we should take action to prioritize saving their life, unless we are highly certain about the validity of their advance directives.

E-learning on medical emergencies for Dentistry students: a randomized controlled trial / E-learning em emergências médicas para estudantes de Odontologia: um ensaio clínico randomizado

This study comparedtwo teaching pedagogies to addressmedical emergencies in dental officevisitsandevaluateddental school students' knowledge about medical emergencies.This randomized controlled trial involved54senior undergraduate dental students at theFederal University of Santa Mariadivided in two groups:students who received instruction via face-to-face traditional expository class;andstudents whoreceived the same instruction via distant learning format.The students were randomly allocated to the groupsby the randomiser.orgwebsite. Data were obtained by comparing the scores students received from answering to a semi-structured questionnaire containing inquiries on ethical and legal implications, and diagnosis and management of medicalemergencies in a dental officebefore and after the instruction. Before the instruction, 96%of studentsfrom the two groupslackedknowledge about the ethical and legal implications related to the dentist obligation to deal with medical emergencies. After the instruction, both groups increasedtheir knowledge similarly as there was no significant difference in the comparison between learning about medical emergencies through lectures and thorough an e-learning format.Both teaching methods presented satisfactory results, which makes the e-learning method an option as a didactic strategy (AU).

Esteestudocomparouduaspedagogiasdeensinoparalidarcomemergênciasmédicasemconsultasodontológicaseavaliouoconhecimentodealunosdocursoodontologiasobreemergênciasmédicas.Esteensaioclínicorandomizadoenvolveu54alunosdoúltimoanodocursodeodontologiadaUniversidadeFederaldeSantaMaria,divididosemdoisgrupos:alunosquereceberaminstruçãopormeiodeaulaexpositivatradicionalpresencial;ealunosquereceberamamesmainstruçãopormeiodoformatodeensinoadistância.Osalunosforamalocadosaleatoriamenteaosgrupospelositerandomiser.org.Osdadosforamobtidospormeiodacomparaçãodaspontuaçõesrecebidaspelosalunosaoresponderaumquestionáriosemiestruturadocontendoindagaçõessobreimplicaçõeséticaselegais,ediagnósticoemanejodeemergênciasmédicasemconsultórioodontológicoanteseapósainstrução.Antesdainstrução,96%dosalunosdosdoisgruposdesconheciamasimplicaçõeséticaselegaisrelacionadasàobrigaçãododentistaemlidarcomemergênciasmédicas.Apósainstrução,os dois grupos aumentaram seus conhecimentos de forma semelhante,poisnãohouvediferençasignificativanacomparaçãoentreoaprendizadosobreemergênciasmédicaspormeiodepalestrasepormeiodoformatoe-learning.Ambososmétodosdeensinoapresentaramresultadossatisfatórios,o que torna o método e-learning uma opção como estratégia didática (AU).

[Current ethical challenges in intensive care in the face of the corona pandemic]. / Aktuelle ethische Herausforderungen in der Intensivmedizin angesichts der Corona-Pandemie.

In view of dramatically increasing patient numbers worldwide in the face of the corona pandemic and scarce resources in intensive care medicine in many countries, some of which are dramatically undersupplied, concerns and fears have spread among the population in Germany. Healthcare workers didn't know how to deal with an overload of the healthcare system. Numerous inquiries from concerned physicians as well as ethics committees prompted the German Interdisciplinary Association for Intensive Care and Emergency Medicine (DIVI) together with seven other medical associations to work out a clinical-ethical recommendation on "Decisions on resource allocation in emergency and intensive care in the context of the COVID-19 pandemic".

Confidentiality and Capacity.

This article focuses on confidentiality and capacity issues affecting patients receiving care in the emergency department. The patient-physician relationship begins with presumed confidentiality. The article also clarifies instances where a physician may be required to break confidentiality for the safety of patients or others. This article then discusses risk management issues relevant to determining a patient's capacity to accept or decline medical care in the emergency department setting. Situations pertaining to refusal of care and discharges against medical advice are examined in detail, and best practices for mitigating risk in informed consent and barriers to consent are reviewed.

Clinical and ethical challenges for emergency departments during communicable disease outbreaks: Can lessons from Ebola Virus Disease be applied to the COVID-19 pandemic?

EDs fulfil a frontline function during public health emergencies (PHEs) and will play a pivotal role during the COVID-19 pandemic. This perspective article draws on qualitative data from a longitudinal, ethnographic study of an Australian tertiary ED to illustrate the clinical and ethical challenges faced by EDs during PHEs. Interview data collected during the 2014 Ebola Virus Disease PHE of International Concern suggest that ED clinicians have a strong sense of professional responsibility, but this can be compromised by increased visibility of risk and sub-optimal engagement from hospital managers and public health authorities. The study exposes the tension between a healthcare worker's right to protection and a duty to provide treatment. Given the narrow window of opportunity to prepare for a surge of COVID-19 presentations, there is an immediate need to reflect and learn from previous experiences. To maintain the confidence of ED clinicians, and minimise the risk of moral injury, hospital and public health authorities must urgently develop processes to support ethical healthcare delivery and ensure adequate resourcing of EDs.

Financial Conflicts of Interest Among Emergency Medicine Journals' Editorial Boards.

STUDY OBJECTIVE: We aim to characterize the prevalence of financial conflicts of interest among emergency medicine journal editorial board members. METHODS: We conducted a cross-sectional study of editorial board members of leading peer-reviewed emergency medicine journals. A list of highly cited emergency medicine journals was curated with Journal Citation Reports and Google Scholar Metrics. Financial conflicts of interest were obtained by curating the Centers for Medicare & Medicaid Services' Open Payments database for the most recently available data (2017). The outcomes of this study were prevalence of financial conflicts of interest and frequency of disclosure on each journal's Web site. RESULTS: Editorial boards of the top 5 journals were analyzed. Of the 198 unique US-based physician-editors, 60 (30.3%) had a financial conflict of interest documented as general or research-based payments. The 52 editors with general payments had a median of 2 payments (interquartile range [IQR] 1 to 8.25), with a median of $202 (IQR $69 to $7,386); the maximum general payment was $115,730 received from industry. For research payments, 26 editors (13.1%) had a median 4 payments (IQR 2 to 9), with a median of $47,095 (IQR $5,328 to $126,025) and maximum of $3,590,000 received from industry. Seven editors in one of the emergency medicine journals included in this study publicly disclosed competing interests; dollar amounts were not reported. CONCLUSION: Nearly one third of US-based editors at leading emergency medicine journals had financial conflicts of interest, although only one journal publicly disclosed the presence of payments. Public disclosure of editorial board members' financial relationships with industry may allow for more transparency related to the content published in these journals.

Compensation models in emergency medicine: An ethical perspective.

There is considerable diversity in compensation models in the specialty of Emergency Medicine (EM). We review different compensation models and examine moral consequences possibly associated with the use of various models. The article will consider how different models may promote or undermine health care's quadruple aim of providing quality care, improving population health, reducing health care costs, and improving the work-life balance of health care professionals. It will also assess how different models may promote or undermine the basic bioethical principles of beneficence, non-maleficence, respect for autonomy, and justice.

Research Methods and Ethics in Health Emergency and Disaster Risk Management: The Result of the Kobe Expert Meeting.

In October 2018, at Asia Pacific Conference for Disaster Medicine (APCDM), an expert meeting to identify key research needs was organized by the World Health Organization (WHO) Centre for Health Development (WHO Kobe Centre (WKC)), convening the leading experts from Asia Pacific region, WHO, WHO Thematic Platform for Health Emergency and Disaster Risk Management (Health-EDRM) Research Network (TPRN), World Association for Disaster and Emergency Medicine (WADEM), in collaboration with Asia Pacific Conference for Disaster Medicine (APCDM) and Japan International Cooperation Agency (JICA). International experts, who were pre-informed about the meeting, contributed experience-based priority issues in Health-EDRM research, ethics, and scientific publication. Two moderators, experienced in multi-disciplinary research interacted with discussants to transcribe practical issues into related methodological and ethical issues. Each issue was addressed in order to progress research and scientific evidence in Health-EDRM. Further analysis of interactive dialogues revealed priorities for action, proposed mechanism to address these and identified recommendations. Thematic discussion uncovered five priority areas: (1) the need to harmonize Health-EDRM research with universal terms and, definitions via a glossary; (2) mechanisms to facilitate and speed up ethical review process; (3) increased community participation and stakeholder involvement in generating research ideas and in assessing impact evaluation; (4) development of reference materials such as possible consensus statements; and (5) the urgent need for a research methods resource textbook for Health-EDRM addressing these issues.

Emergency physician care of family members, friends, colleagues and self.

Emergency Physicians are frequently called upon to treat family members, friends, colleagues, subordinates or others with whom they have a personal relationship; or they may elect to treat themselves. This may occur in the Emergency Department (ED), outside of the ED, as an informal, or "curbside" consultation, long distance by telecommunication or even at home at any hour. In surveys, the vast majority of physicians report that they have provided some level of care to family members, friends, colleagues or themselves, sometime during their professional career. Despite being common, this practice raises ethical concerns and concern for the welfare of both the patient and the physician. This article suggests ethical and practical guidance for the emergency physician as to how to approach these situations.

Physician-assisted Death: Ethical Implications for Emergency Physicians.

Physician-assisted death (PAD) has long been a strongly debated moral and public policy issue in the United States, and an increasing number of jurisdictions have legalized this practice under certain circumstances. In light of changing terminology, laws, public and professional attitudes, and the availability of published data about the practice, we review key concepts and terms in the ongoing PAD debate, moral arguments for and against PAD, the current legal status of PAD in the United States and in other nations, and data on the reported experience with PAD in those U.S. jurisdictions where it is a legal practice. We then identify situations in which emergency physicians (EPs) may encounter patients who request PAD or have attempted to end their lives with physician assistance and consider EP responses in those situations. Based on our analysis, we offer recommendations for emergency medical practice and professional association policy.

Association between emergency physician self-reported empathy and patient satisfaction.

BACKGROUND: Higher physician self-reported empathy has been associated with higher overall patient satisfaction. However, more evidence-based research is needed to determine such association in an emergent care setting. OBJECTIVE: To evaluate the association between physician self-reported empathy and after-care instant patient-to-provider satisfaction among Emergency Department (ED) healthcare providers with varying years of medical practice experience. RESEARCH DESIGN: A prospective observational study conducted in a tertiary care hospital ED. METHODS: Forty-one providers interacted with 1,308 patients across 1,572 encounters from July 1 through October 31, 2016. The Jefferson Scale of Empathy (JSE) was used to assess provider empathy. An after-care instant patient satisfaction survey, with questionnaires regarding patient-to-provider satisfaction specifically, was conducted prior to the patient moving out of the ED. The relation between physician empathy and patient satisfaction was estimated using risk ratios (RR) and their corresponding 95% confidence limits (CL) from log-binomial regression models. RESULTS: Emergency Medicine (EM) residents had the lowest JSE scores (median 111; interquartile range [IQR]: 107-122) and senior physicians had the highest scores (median 119.5; IQR: 111-129). Similarly, EM residents had the lowest percentage of "very satisfied" responses (65%) and senior physicians had the highest reported percentage of "very satisfied" responses (69%). There was a modest positive association between JSE and satisfaction (RR = 1.04; 95% CL: 1.00, 1.07). CONCLUSION: This study provides evidence of a positive association between ED provider self-reported empathy and after-care instant patient-to-provider satisfaction. Overall higher empathy scores were associated with higher patient satisfaction, though minor heterogeneity occurred between different provider characteristics.

How Should Trauma Patients' Informed Consent or Refusal Be Regarded in a Trauma Bay or Other Emergency Settings?

The precipitous and unexpected nature of trauma requires training health care practitioners to think and act quickly, according to the best medical interest of the patient. The urgency of treatment for trauma patients, who frequently have temporary alterations in their abilities to make autonomous and competent decisions, often results in presumed consent for medically necessary treatment. Academic trauma centers use protocol-based management of injuries to facilitate their simultaneous evaluation by multiple clinicians and to avoid delays in treatment, ensuring that trauma patients receive the best possible care. In this article, we will discuss the issues of deferred informed consent and surgical education as they relate to trainees' graduated responsibility in the trauma bay.

Revisiting the Jewish Ethical Approach Toward Perimortem Cesarean Section in Light of Emerging Medical Evidence.

BACKGROUND: Maternal cardiac arrest during gestation constitutes a devastating event. Training and anticipant preparedness for prompt action in such cases may save the lives of both the woman and her fetus. OBJECTIVES: To address a previous Jewish guideline that a woman in advanced pregnancy should not undergo any medical procedure to save the fetus until her condition is stabilized. METHODS: Current evidence on perimortal cesarean section shows that immediate section during resuscitation provides restoration of the integrity of the mother's vascular compartment and increases her probability of survival. We analyzed Jewish scriptures from the Talmud and verdicts of the oral law and revealed that the Jewish ethical approach toward late gestational resuscitation was discouraged since it may jeopardize the mother. RESULTS: We discuss the pertinent Jewish principles and their application in light of emerging scientific literature on this topic. An example case that led to an early perimortem cesarean delivery and brought about a gratifying, albeit only partially satisfying outcome, is presented, albeit with only a partially satisfying outcome. The arguments that were raised are relevant to such cases and suggest that previous judgments should be reconsidered. CONCLUSIONS: The Jewish perspective can guide medical personnel to modify and adapt the concrete rules to diverse clinical scenarios in light of current medical knowledge. With scientific data showing that both mother and fetus can prosper from immediate surgical extrication of the baby during resuscitation of the advanced pregnant woman, these morals should dictate training and practice in urgent perimortal cesarean sections whenever feasible.

Assessment of consent models as an ethical consideration in the conduct of prehospital ambulance randomised controlled clinical trials: a systematic review.

BACKGROUND: We sought to understand the main ethical considerations when conducting clinical trials in the prehospital ambulance based setting. METHODS: A systematic review of the literature on randomised controlled trials in ambulance settings was undertaken. A search of eight databases identified published studies involving recruitment of ambulance service users. Four independent authors undertook abstract and full-text reviews to determine eligibility and extract relevant data. The data extraction concentrated on ethical considerations, with any discussion of ethics being included for further analysis. The resultant data were combined to form a narrative synthesis. RESULTS: In all, 56 papers were identified as meeting the inclusion criteria. Issues relating to consent were the most significant theme identified. Type of consent differed depending on the condition or intervention being studied. The country in which the research took place did not appear to influence the type of consent, apart from the USA where exception from consent appeared to be most commonly used. A wide range of terms were used to describe consent. CONCLUSIONS: Consent was the main ethical consideration in published ambulance based research. A range of consent models were used ranging from informed consent to exception from consent (waiver of consent). Many studies cited international guidelines as informing their choice of consent model but diverse and sometimes confused terms were used to describe these models. This suggests that standardisation of consent models and the terminology used to describe them is warranted.

"Futile Care"-An Emergency Medicine Approach: Ethical and Legal Considerations.

Futility often serves as a proposed reason for withholding or withdrawing medical treatment, even in the face of patient and family requests. Although there is substantial literature describing the meaning and use of futility, little of it is specific to emergency medicine. Furthermore, the literature does not provide a widely accepted definition of futility, and thus is difficult if not impossible to apply. Some argue that even a clear concept of futility would be inappropriate to use. This article will review the origins of and meanings suggested for futility, specific challenges such cases create in the emergency department (ED), and the relevant legal background. It will then propose an approach to cases of perceived futility that is applicable in the ED and does not rely on unilateral decisions to withhold treatment, but rather on avoiding and resolving the conflicts that lead to physicians' believing that patients are asking them to provide "futile" care.

Conflicts of Interest in Emergency Medicine.

Conflicts of interest (COIs) are common in the practice of emergency medicine and may be present in the areas of clinical practice, relations with industry, expert witness testimony, medical education, research, and organizations. A COI occurs when there is dissonance between a primary interest and another interest. The concept of professionalism in medicine places the patient as the primary interest in any interaction with a physician. We contend that patient welfare is the ultimate interest in the entire enterprise of medicine. Recognition and management of potential, real, and perceived COIs is essential to the ethical practice of emergency medicine. This paper discusses how to recognize, address, and manage them.