Author Credentials

Author: Erin E. Dancour, MD, MS, FACEP, Columbia University

Editor: Matthew Tews, DO, MS, Medical College of Wisconsin

Objectives

1. Identify the four major ethical principles of the doctor-patient relationship
2. Understand the obligations of a mandated reporter
3. List the agencies that investigate possible harm or neglect of those who cannot care for themselves
4. Appreciate the challenges of following a patient’s direction when those decisions are in conflict with their family’s wishes
   

Case 1

Your first patient of the day is Mr. J. M., a very nice 58 year old man who was visiting his brother here in town when he became ashen, sweaty and admitted to his family that he was having chest pains. His brother insisted on bringing him to the Emergency Department, where his EKG shows ST depressions in V4, V5 and V6. The lab calls you with a critical result: his troponin is 130 (negative: under 0.01). You return to the patient’s bedside, where he remains stable appearing and says he feels much better. A repeat EKG shows ST elevations in the anterior leads V1 and V2. You explain to him that he is having a heart attack and the treatment is cardiac catheterization to re-establish blood flow to his heart in order to prevent more damage to his heart and possibly save some injured heart muscle. He thoughtfully responds “I would prefer not to stay in the hospital – I feel okay now and I don’t like hospitals. I want to go home.” He is sober, alert and oriented, and can express your concerns when you ask him to demonstrate understanding of the situation. He states “I just don’t feel like I should stay in the hospital if I’m not having pain. I feel fine now. I will come back if anything happens. I’d prefer to go home now – can you discharge me?” What do you do?

• Would you discharge J.M. from the hospital?
• Would you make him leave against medical advice (AMA)?
• Would you refuse to let him leave?

When a patient comes to the Emergency Department for help, they have a right to emergency stabilization whether or not they have the ability to pay and regardless of their age, gender, race, or beliefs. This right has been written into law, under the Emergency Medical Treatment and Active Labor Act (EMTALA). Emergency Physicians must perform an assessment and stabilize a patient prior to transferring them or discharging them. That means that Emergency Physicians form many new Physician-Patient relationships each day with each new patient.
The physician-patient relationship is a special and privileged relationship based on four major ethical principles:

Beneficence

We have the duty to serve our patients’ best interests by treating or preventing disease or injury and by informing patients about their conditions. We also must protect our patients’ right to confidentiality.

Nonmaleficience

Do no harm. This is the reason patients trust us – they have faith in us that we will not harm them.

Autonomy

Adult and emancipated patients with decision-making capacity have the right to accept or decline offered health care, and physicians have a duty to respect the decisions of their patients.

Justice

We must be fair and impartial to patients’ gender, race, age, ability to pay and demeanor when we treat them, regardless of one’s own beliefs.

When Mr. J. M. presented to the Emergency Department, he was immediately seen by the medical team because his complaint of chest pain was considered to be of greater potential danger to his health than the complaint of another patient who came to the E.D. ten minutes prior to Mr. J. M. did. Which principles of ethical patient care were enacted from the moment J. M. arrived?

• Beneficence: We acted immediately to diagnose the source of his chest pain
• Non-maleficence: We didn’t neglect his care or see others ahead of him when we feared that his presenting complaint could represent something serious
• Justice: We treated our patient the way that we would want to be treated

What do we do when our respect for patient autonomy and beneficence seem to work against one another? We can offer beneficent care but a patient’s autonomy directs whether or not they accept that care. Even if a patient does not agree with our treatment recommendations, we can provide them with compassionate counseling and should assist them and stabilize them as completely as we are able.

After a heartfelt conversation with Mr. J. M., he expresses that he understands your concerns and fears. He understands that you think his heart could be permanently damaged beyond repair, leading to heart failure, arrhythmias or death within the next few days. He is sober, does not wish to harm himself, and expresses that he wants to go home to mull over his treatment options. You openly invite him to return to the ED any time that he wants and if he changes his mind, you alert triage to his situation in case he returns so that they can rapidly triage him and he can be immediately seen if he returns, and you discharge him from the ED making an extensive note that he declined therapy and left against medical advice. He returned to the Emergency Department in an ambulance an hour later because his chest pain returned when he got home, and this time he agrees to undergo catheterization and thanks you for being patient and compassionate with him during his first visit to the ED, admitting he wouldn’t have returned to the hospital at all if he hadn’t been so impressed by your respect of his right to autonomy. He is later diagnosed with severe heart failure.

Case 1 Pearls

• Beneficence describes our overall goal to help our patients
• Nonmaleficence is the principle that we should not harm our patients
• Autonomy is our duty to respect our patient’s wishes
• When we treat our patients rightfully despite their lifestyle or creed, we are upholding medical justice
• If you openly consider these principles when you find yourself in an ethics dilemma, they can help you to make challenging decisions

Case 2

Your second patient of the day is Ms. R. S., a 21-year-old female with an arm laceration. She explains “I lost my balance in the kitchen while I was heating up lasagna” at 6am, and appears to be intoxicated and smells strongly of alcohol. She explains that she was heating up the lasagna to feed her four-year-old brother breakfast as she was babysitting him. You ensure that the toddler is not home alone by confirming that he is with their neighbors. She admits that she was the only person at home with him this morning, and she admits “last night I drank a lot because I was out with friends”. What are your ethical duties in this case? You are concerned because she was drunk while babysitting a child, but now he is in safe hands.

• Do you need to do anything in this situation?
• Who could this case be reported to?
• If you report this case, won’t you be violating your patient’s right to privacy?

Patients have the right to privacy, and you must strive to act in a beneficent manner to protect your patient’s basic rights, including the rights to health, safety, and privacy. Sometimes, a patient’s right to privacy conflicts with the interests of someone who you aren’t treating in the ED. Which is a greater responsibility: the responsibility of respecting your patient’s privacy or the responsibility to protect others? In cases where a patient is an imminent danger to themselves or others, you are obligated to protect the patient and others. That may mean holding a psychotic or homicidal patient in the hospital against their will until you have input from social work and psychiatry that reassures you that the patient is no longer dangerous. It means that if a patient has an incurable or dangerously virulent disease that they could spread to others and are keeping that disease a secret, you are obligated to warn those at risk. If a patient admits they plan to harm another person, you are obligated to warn that person. Social workers and psychiatry teams are very good at assisting you in this process, but the responsibility to protect the patient and anyone threatened falls upon you.

• What about patients who are negligent towards a vulnerable person?
• What about patients who may be unable to care for a vulnerable person?

We frequently treat patients who are elderly or young and unable to care for themselves. Some of our patients or family members of our patients cannot feed themselves, clean themselves or keep themselves safe without assistance. If a vulnerable person is seen in the emergency department and you suspect that their basic needs are not being met, or if a caregiver is treated in the emergency department and you are worried that they may not be able to provide the type of care that they have assumed the responsibility to provide, you are obligated to report suspected neglect or abuse.

• You think that the child in this case may not have been supervised adequately this morning, but they’re probably well supervised at other times. Do you need to report this particular case today?
• What if you report a potentially unsafe situation and you’re wrong?

Physicians are mandated reporters, which means that we are legally mandated to report suspected abuse or neglect. Schoolteachers, priests, nurses, and many others are also mandated reporters. If you are worried about a patient or someone who your patient cares for, report your concern without hesitation. Child protective services (CPS) specializes in investigating and ensuring safe care for children. Adult protective services (APS) does the same for elderly patients and other adults who cannot care for themselves fully, such as disabled adults or mentally handicapped adults. If you report a concern, you don’t need to be correct. You aren’t a judge. Your job is to merely report your concern so that it can be investigated. If an investigation reveals that a vulnerable person isn’t getting enough care or assistance at home, they can help to ensure that the neglected person gets the help that they need, which could include home nurse care, education for the care provider, or placement in a different home. If a child in the emergency department doesn’t have a safe home, you must admit the child to the hospital or ensure that they remain in the ED while CPS and social workers arrange safe care for the child.

If you report concern for a person in good faith and the investigation doesn’t turn up abuse or neglect, you cannot be sued or fired for your report. More importantly, you did what you could to make sure that a vulnerable person is getting the help that they need. However, if you don’t report something that concerns you and sends up red flags in your mind and a child or elderly person is injured or abused, you are responsible for that injury or abuse because you didn’t report your fears. You’re responsible for failure to report legally and can lose your license to practice medicine, and you’re also ethically responsible for failing to protect those who need your help. Social workers are usually available to help you to make a report, and CPS and APS hotlines and websites also help to walk you through the steps of mandated reporting.

You speak more extensively with the patient and discover that she is not usually the babysitter for her brother. She is only visiting briefly and is the babysitter for a single morning while her mother and father are at a medical appointment. You called the hospital’s social worker to come and see the patient in the ED, and you ask the patient for permission to call her mother and father to explain the situation and pick their son up at the neighbors’ home. She gives you permission.

• What would you have done if she had refused to allow you to call the boy’s parents?

If a child needs supervision, their guardian must be contacted. Whenever possible, you can reach out to guardians without violating your patient’s confidentiality to let them know that you’re treating the child’s caregiver and need help with arranging supervision for the child in the meantime. If you show empathy and concern towards your patient they’ll frequently give permission to call the parents and discuss the whole situation, which may help the parents to make responsible future babysitting decisions.

After calling the child’s parents to explain that he is being cared for by his neighbors, you contact child protective services and they open an investigation and reassure you that they will visit the home today to speak with the child’s parents and assess the home for safety. You carefully repair the patient’s arm laceration and when she appears sober, you counsel her in a heartfelt way about the importance of sobriety while caring for a child and offer alcohol abuse counseling. You discharge your patient from the emergency department. A week later the social worker who helped you to report the case to CPS lets you know that CPS investigated the case and the child was found to be safe at home and the parents do not plan to let their daughter babysit for them again.

Case 2 Pearls

• Physicians are mandated reporters. That means we are mandated to report situations that are placing others outside of our care at risk to the correct authorities.
• Child protective services specializes in investigating cases of child abuse or neglect.
• Adult protective services specializes in investigating cases of abuse or neglect of the elderly or of adults who cannot fully care for themselves
• If you report suspected abuse or neglect in good faith, you will not get into trouble for reporting your suspicions or fears

Case 3

Your third patient of the afternoon is Mr. L. G., an elderly man with metastatic cancer and pneumonia with sepsis. He is initially alert in the ED so you ask him about his wishes if his condition were to worsen. He clearly affirms to you that he does not wish to be intubated or to receive CPR because he has been fighting cancer for a long time and doesn’t feel that heroic measures would be in his best interests. He also declines placement of a central line for aggressive care of his sepsis. He begins to grow confused as his blood pressure gradually drops, and you call his family to be at his bedside because you suspect that he is close to death. His son arrives in the ED and becomes very upset when he sees his father dying. His son demands that the patient should have a central line placed and that he should be intubated, and when you compassionately explain that his father had expressed that he did not want a central line or to be intubated, his son argues “My father would never want that – our beliefs are that we should do everything to stay alive. My father must have been confused because he’s so sick.” You feel that his father was not confused and expressed his wishes knowingly and genuinely, and his son is furious and accuses you of trying to kill his father by withholding care that he would want and threatens to sue you and the hospital for murder. The patient is now barely conscious and unaware of his surroundings.

• What should you do?
• Should you treat the patient with invasive therapy now that he is confused and doesn’t know what is happening to him any longer?

Family members are frequently wonderful advocates for one another, but sometimes they have an incomplete understanding of their own parents’ wishes or children’s wishes, and that incomplete understanding can lead to huge conflict in the ED in emotionally charged situations. Different religious groups and national backgrounds approach decisions surrounding death in different ways. You will encounter families that are very stoic and families that are very outwardly emotional. Some families are all on the same page, some families are wonderful at designating a single decision maker to express a dying or incapacitated family member’s wishes and to make decisions on their behalf, and some families are thrown into chaos with a confusing mix of opinions on the table in life-or-death situations. As an emergency physician, you need to be able to identify the situation at hand and juggle the various personalities involved in an effort to make everyone felt like they have been heard while also helping the family come to a sound and clear decision.

• What should I say if someone asks me what I think they should do in their situation?

Sometimes families prefer to have huge amounts of information and then they weigh this information and make elaborate decisions, sometimes with the input of their religious leaders. Frequently, families ask you what you think they should do. In that situation, be honest and clear and genuinely open with them and they will frequently follow your suggestion. If you don’t know what to tell them, then be open about that as well and then suggest what you might do in their situation, always being gracious to express that you have deep empathy for the difficult decisions that they are making and that you deeply respect their decision-making process.

• When do the wishes of the patient’s family take precedence over the wishes of the patient?

When a competent adult patient expresses their personal wishes for their healthcare, that information must be respected above all other directives, even if thirty family members disagree vehemently. If a person is of sound mind and wishes to accept or decline offered care and they are informed about what that decision may entail, that decision is the bottom line. If someone’s father or mother or sister or brother dies, that is a traumatic and difficult event for the family member. However, it is most important to respect the wishes of the person who is living or dying in the process, and sometimes you need to aggressively advocate for your patient. This respects their personal autonomy. To allow someone to die without performing CPR or intubating them if they do not wish for those interventions is to be ultimately non-maleficent. You aren’t a murderer if you fail to prolong someone’s life in accordance with their wishes to limit their perceived suffering.

• Is withholding medical therapy at your patient’s direction the same as helping your patient to commit suicide?

In some states and in some other countries, actively prescribing a quantity of medicine to hasten or cause death at the direction of a competent and well-minded patient is legal. The ethics of that decision are hotly debated. However, withholding heroic measures in respect for one’s wishes are a very different thing, and they are not active allowance of death, nor do such actions cause death. They merely avoid certain potentially challenging situations that oftentimes prolong death or delay death or sometimes prevent it.

• How can you prevent emotionally charged chaos in the Emergency Department when you refuse to honor a relative’s wishes for your patient?
• They’re threatening to sue me here, and there’s a lot of them and only one of me. How can I get some help?

In situations of family conflict, it is important to remain emotionally gracious and open with families and to attempt to diffuse the emotionally charged nature surrounding the conflict. That takes practice and experience, and diffusing a difficult and conflicting situation is not always possible. If you feel as though you are getting into trouble because of conflict in the ED, summon help. If you know what the right thing to do happens to be, stand your ground. If you don’t know what the right decision is, get help from an ethics consultation or patient representative, an emergency medicine administrator, the chaplain, or anyone at your disposal. The more backup you have, the better. Sometimes, another personality joining the fray will help to diffuse the conflict better than you alone because if you are the first physician to put up resistance to a family member’s wishes, they may feel embittered towards you even if you are extraordinarily diplomatic. Use the tools at your disposal, because taking action to advocate for a patient is the greatest way that you can show respect for your patient, regardless of what your thoughts or wishes might be for them, and you must do so while attempting to provide the most positive and compassionate experience possible for their family, who is also suffering in a different way.

You summon assistance by calling for a patient representative to join you and you page the medical ethicist so that you can have support at your side, as the patient’s son is already furious with you and it’s possible that he could have an improved and more productive relationship with other personalities and communication styles from other medical care providers. You explain the situation to the medial ethicist and the patient representative, and you stand your ground because you feel that you must advocate for the patient, especially now that your patient can no longer advocate for himself. The medical ethicist supports your need to uphold the patient’s wishes and speaks with the patient’s son and other family members who are now arriving in the ED and the chaplain speaks with the family graciously and extensively. The family has a long and heated discussion and two family members are angry, the rest of the family is compassionately understanding and advocates for their father’s expressed wishes to remain DNR/DNI. The family refuses to elect a single spokesperson because there is conflict within the family and all remain at the patient’s bedside. He is admitted to the ICU on peripheral vasopressors and dies the next day from sepsis. He never appears to be in pain or wakes up after his ED assessment.

Case 3 Pearls

• A competent adult patient has the right to accept or refuse any offered medical care, and the patient’s wishes take precedence over the wishes of their family members
• If a patient expressed healthcare wishes while competent and then becomes ill and cannot make their own decisions, their most recently known wishes must be honored
• While you must act as an advocate for your patient above all others, if you express empathy towards their family in times of conflict, your affect can greatly decompress chaos and tension
• If you need help with an angry family in the ED, ask for help
  

References

• “ACEP Code of Ethics for Emergency Physicians.” A Compendium of ACEP Policy Statements on Ethical Issues Revised 2002, 2003, 2004, 2005, 2006, 2007, 2008, 2009, 2011, 2012, 2013, 2014: 1-12. Clinical & Practice Management. Web. 1 Dec. 2015.
• Adams, James. “Ethical Challenges in Emergency Medical Services.” Ed. Herbert Garrison and Normal Dinerman. Prehospital and Disaster Medicine (1993): 1-8. Web.
• Schmidt, Terri, Beckman Girod, Stephanie Hollingsworth, Jason Hughes, Jayne MacLaughlin, Catherine Marco, Brian McBeth, Katie McClure, Tammie Quest, Raquel Shears, and Drew Watters. “Guide to Teaching Ethics in Emergency Medicine Residency Programs.” SAEM Ethics Committee (2005): 1-95. Web. 1 Dec. 2015.