Working in the emergency department gives rise to unique ethical considerations.
Ethical problems are often exacerbated by time constraints, lack of detailed information, and a high incidence of impaired cognitive abilities in the patients.
When patients arrive in the ED, the triage nurse has little time to gather detailed information. nstead, a quick assessment is completed and actions are taken based on protocols, rather than the patient's preferences.
Nursing in the ED is a complex and specialized practice where highly complex, and invasive interventions are often executed without obtaining informed consent from the patient or the surrogate.
Ethics & Expectations
The Emergency Nurses Association has published a Code of Ethics by which ED nurses are to guide their practice.1
The code of ethics directs nurses to maintain their high competence levels, exercise sound judgment in protecting the lives and privacy of patients and their families, and to practice with compassion, giving respect for human dignity, and respecting each individual for whom they are.1
The expectation of services in the ED is to treat patients as well as inform them of their medical conditions. Overall, the goals of the ED staff are to quickly treat acute illnesses and injuries, minimize suffering and loss of functioning, and protect life. In the execution of the goals is the ethical principle of beneficence - or the obligation of staff - to improve the outcome for the patient.
When patients are unable to make decisions for them, the duty of the ED nurse is to advocate beneficence. This means to provide an objective view of what is best for the patient. This concept can become challenging when conflicts exist between clinically indicated treatment and the patient's religious or cultural values.
An example of this is during active CPR when ED staff are performing an extensive variety of aggressive medical treatments without seeking approval or consent from any legal representative of the patient.
The resuscitation efforts may conflict with the patients religious or cultural beliefs in regard to the receipt of blood products; however, this is in the best interest of the patient and is a reflection of beneficence.
Autonomy Begets Responsibility
Autonomy brings with it an obligation to respect the choices of others, such as a patient's right to self-determination.
It is the role of the ED nurse to ensure patients have accurate and comprehensive information to make informed decisions regarding treatment.
Additionally, the nurse needs to ensure patients understand the potential benefits and success of certain procedures, but that outcomes are not guaranteed.
In some instances, patients may need to be treated without informed consent if the intervention is essential to the preservation of life. However, when a treatment can result in serious harm, informed consent must be obtained.
The decisions people make may appear to be irrational, but if they are consistent with their internally-held beliefs, the nurse must advocate for them, as outlined by the American Nurses Association Code of Ethics.2
"Nurses have the responsibility to promote health, and to advocate for the protection of the safety and self-demining rights of the patient," ANA says.
This means the nurse must also advocate for terminally ill patients who choose to forgo life-sustaining treatment, as expressed verbally, in a living will, or a form of communication that is appropriately executed on the behalf of the patient.2
Nurses must also act fairly to all persons regardless of gender, race, socioeconomic status, cultural background, or the ability to pay.
All patients have the right to a standard of care as outlined in the Emergency Medical Treatment and Active Labor Act, which mandates access to quality emergency medical treatment to all whom seek it.3
The concept of nonmalficence, meanwhile, means to cause no harm, which is crucial to maintaining the integrity of staff and patient trust. ED nurses must ensure the safety of their patients in their care to the best of their ability.
Additionally, it is the responsibility of the nurses to protect themselves, their coworkers and their patients against violent acts by known perpetrators, other patients or visitors. When violence is beyond that which can be handled by the nursing staff, then authorities must be brought in.
Determining Decisional Capacity
Like nurses, patients also have ethical obligations. They are expected to participate in their own care while collaborating and cooperating with ED staff, and should respect triage decisions and prioritization.
Patients must always provide informed consent autonomously and voluntarily. This is achieved when patients are competent to agree or disagree to with proposed interventions and can sign consent their name.
For those who are not competent or are unable to sign the consent forms, a surrogate will then assume responsibility. If a surrogate is not available, attempts will be made to contact one through acceptable modes of communication. In some cases, patients may request that the ED physician make the decisions for them.
Determining decisional capacity involves assessment of patients' ability to understand their and deliberate and articulate their healthcare preferences. Decisional capacity is dynamic and can improve or decline rapidly in an emergency setting.
Diminished decisional capacity can vary during an emergency and can be reversible in certain states, such as intoxication, hypoxia, sedation and extreme stress. All efforts should be made to ensure the reversible cases are treated so the patient can make the most rational and autonomous choices.
Decisional capacity is assessed in each ED patient, using indices such as ability to give a reasonable medical history, to cooperate with evaluation, and to understand the recommended treatments. Refusing to have a small laceration suture is one thing, but being unwilling to be admitted for treatment following a cardiac event is another.
Enter, implied consent, which based on the assumption that every rationale human being wants to live as long as possible (O'Neill, 2003).4 Consent is implied when it is impossible to be obtained immediately prior to performing a life-saving intervention or treatment (University of Washington School of Medicine, 2011).5
In emergency situations, staff should attempt to consult with the patient's attending physician or with another physician, and this transaction must be noted in the documentation. Included in the documentation should be clear identification of the threat to life or health, the immediacy and the magnitude of the emergency.
When a person is unable to give consent, staff acts in accordance with the ethical concepts of "doing the greatest good" for each patient based on the implied consent or "What would I do if this were me?" while simultaneously applying the standard ethical principles of practice.
The concept of medical futility is based on the notion of commonsense and acceptable levels of probability.
In essence, futile treatments are those that preserve permanent states of unconsciousness, or fail to end a patient's total dependence on intensive medical treatment (University of Washington School of Medicine, 1998).6
In the ED, staff must be especially aware of this concept because of time constraints, or absence of relatives or ability to communicate with the patient.
Some treatments are automatically carried out in the ED often before a detailed history has been obtained. Electronic records assist in these situations, but electronic records are not yet universal, lack of information continues to present difficulty.
Additionally, consideration that future treatments may be futile is not basis to terminate all current treatments from being performed.
In some cases, supportive measures will be provided, and although certain treatments may be withheld, it is important to remember to maintain the support comfort measures as well as adequate communication for patients, family and friends.
Refusal of Care
Ethically patients have the right to refuse care. It is the responsibility of the ED nurse to ascertain if the patient has enough information to make an informed decision regarding refusal of care.
If the reasoning for the decision is irrational, the nurse is responsible for ensuring that the patient has all necessary information. It is the responsibility of the nurse to make sure the patient has more information by which they can make a better informed decision.
Surrogates and family members that are making decisions must also have enough information in order to ensure the best care for the patient.
Discharge against medical advice is a decision made by the patient to leave the ED prior to the physician recommending discharge.7
In such cases it is essential to obtain informed consent showing the patient has made a decision without being coerced to leave the ED with full knowledge of the risks, benefits and all alternatives to the decision (Alfandre, 2009).7
The act of leaving "against medical advice" should be viewed as a process, and not merely the acceptance of a signature on a form.
In such cases it is incumbent upon nurses to determine the capacity of the patient, evaluate the quality of the delivered information including risks and benefits, and a full documentation of the process.
An ethical problem is one in which no clear answer exists for all.
Nurses' previous experience and education can assist in the decision making process, and nurses should never hesitate to solicit input from colleagues when necessary.
Although algorithms are available to guide care in cases of cardiac arrest and trauma, each patient and situation is unique, and deviations from protocol may be indicated.
Like clinical problems, ethical problems require action for resolution. In most clinical settings, there is adequate time to identify and discuss the relevant ethical issues before decisions are made.
However, this is often not the case in the ED, where ethical problems may require immediate resolution. To promote ethical decision making in these situations, a system to quickly analyze ethical concerns should be in place.
This system can include consideration of the following issues:
- Who are the stakeholders?
- Do time constraints apply?
- What is the chronology of events?
- What medical, social, and legal information is required to facilitate decision making?
- What is the best communication pathway to follow?
- What family values must be considered?
- Is there any consensus that exists with any of the person involved?
The ED is unique from all other specialties in healthcare, and presents in a unique environment with distinct moral challenges.
In order to respond appropriately to these ethical challenges, ED nurses are required to have knowledge of moral concepts and principles, and specialized moral reasoning skills. It becomes import then to identify and promote the moral attributes of those nurses in the ED.
ED nurses have a duty not only to their patients, but to the society in which they live. The nurse is responsible for informing the public, assisting in the allocation of resources in a just manner, opposing violence and promoting public health.
It then becomes the responsibility of the ED nurse to participate in helping craft legislative, regulatory, institutional and educational pursuits that promote the safety of the patient and improve the quality of care.
References for this article can be accessed here.
Stephanie McElroy is a contributor to ADVANCE.