Minors, or patients younger than years-old, cannot provide consent to treatment. Legal gaurdiams, usually parents, need to provide consent. If the minor's parent is unavailable and there is another adult that is taking responsibility, for example a school principal or camp counselor, for the child, they can provide consent until the legal guardian arrives. Some persons that are younger than 18 years old can provide self-consent and are considered emancipated from their guardians and make their own decisions.
They are minors who are married, in any branch of armed services, have a history of pregnancy or are legally emancipated. An adult, or an emancipated minor, and all people have the right to refuse medical treatment regardless of reason. These people have the right to self-control and what happens to their own body, even if it is detrimental. They can self-determine their lives. If a person does not want care and wants to refuse treatment, they have to first to prove that can understand the risks, benefits, and alternatives.
The is a large legal difference between capacity and competence, which is a legal term. EMS providers need to show capacity, not competence. There are many ways to prove capacity that from a medical and legal point of view must be documented before refusal. If the refusing patient can understand the risks, understand alternatives, understands what can happen if they refuse, for example, death or disability, and reiterates this information to the EMS provider in their own words, the EMS provider may document, to the best of their ability, that the patient has or had the capacity to refuse.
We all question our decisions in relation to the care we provide and the circumstances in which we provide it. To ensure that we stay within what society has deemed ethical behavior, it is essential to keep in mind the following:. Ethics are based on accepted standards of right and wrong that prescribe what humans ought to do, usually in terms of rights, obligations, benefits to society, fairness, or specific virtues.
Medical ethics is a branch of ethics that analyzes the practice of clinical medicine and is based on a set of values that professionals can refer to in the case of any confusion or conflict. These values include respect for autonomy, non-maleficence, beneficence, and justice. These values allow clinicians to create treatment plans and work toward the same common goals.
It is important to note that these four values are not ranked in order of importance or relevance and that they all encompass values pertaining to medical ethics. Conflict may arise leading to the need for hierarchy in ethical systems in that some moral elements overrule others with the purpose of applying the best moral judgment to a difficult medical situation.
Many of us try to equate ethics with how we feel. Ethics should not be identified with religion, even though the argument can be made that religions advocate high ethical standards. If ethics were simply regulated to religion, then ethics would apply only to religious people.
Being ethical is also not the same as following the law. While the law generally incorporates ethical standards to which most citizens subscribe, laws, like feelings, can deviate from these standards.
Our own Jim Crow laws or the now overturned apartheid laws of present-day South Africa are examples of laws that deviate from what is ethical. Lastly, this leads us to the understanding that being ethical is not the same as doing whatever society deems as acceptable.
In any society, most people accept standards that are, in fact, ethical. The immediate problem is difficulty getting a good oxygen sat. Patients may be given a diagnosis, a cause and a prognosis. They will be offered treatment options, along with a list of risks and benefits to each. Often, several conversations take place, and the patient will have time for moral deliberation. This discussion is likely to take place over several meetings, as more information is acquired.
The physician will engage the patient in a conversation about her values, possible courses of treatment and end-of-life care. But often, little to no time exists for detailed deliberative decision-making. Decisions must frequently be made quickly. Because EMS providers often have lower levels of education than physicians, as well as less time for consulting colleagues and the professional literature when providing care, and because legal liability lies with the medical director and the service, EMS decision-making tends to be strongly protocol-driven.
The consent conversation would be short and specific to the immediate problem of shortness of breath. In my conversations with EMS providers, many say lying is a useful tool to calm patients, to keep them focused away from bad news or situations, and to permit the EMS provider to offer the best care. The goal is to stabilize and treat the patient--something a sudden grief reaction or pleas to tend to the other person may inhibit.
Ironically, lying enables the EMS provider to form a caring, trusting bond with the patient much faster than if he told the truth. He was just discharged from the hospital last week. The home provider has the patient's advance directive and a copy of a DNR order from his hospitalization. However, there is no prehospital advance directive out-of-hospital DNR.
Patients and family members can complete advance directives and appoint healthcare proxies. Time permits a process of conversing and discussing these issues so that a well-deliberated plan can be made. In the above case, a physician seeing the patient's advance directive would be able to write an immediate DNR order and withhold resuscitation treatment. In many states the PHAD must be the original document and not a copy.
Although it is beyond the scope of an EMS provider's practice to withhold treatment, in reality, EMS providers sometimes do withhold resuscitation without a PHAD or medical director's order. In the above case, an EMS provider would be required to initiate resuscitation and transport. You see just ahead of you that an accident has occurred, and at least one person appears to have gone through his windshield.
A person is running through the stopped traffic asking if anyone can provide medical care. The exception is emergency situations. At work or on personal time, a physician must respond to patients in a medical emergency. Thus, a physician would be obligated to assess and treat the victim in the above scenario. EMS providers have no choice whom to treat;7 likewise, a patient cannot choose a particular EMS provider. While on-duty, the EMS provider must give treatment to anyone who requests it unless doing so would compromise the provider's safety.
However, unlike a physician, an off-duty EMS provider is not legally required to provide care except in Vermont and Minnesota. In other states, the EMS provider would have no requirement to help the victim in the above scenario.
Is there technically a patient? Legally the EMS provider should conduct an examination to ensure there is no life-threatening injury. Ethically, the provider has a duty of beneficence, to protect a patient from harm, suggesting that a properly documented assessment would be appropriate.
Like most ambulances, the responding EMS providers do not stock human blood. A court order, on the other hand, can be rescinded only by the judge who issued it, or by a panel of judges in a court of appeals. I held in my hand a document that had been based on the wishes of a patient, but issued by a judge.
We had a legal obligation to follow it. She was a little girl who, just moments before, had begged me not to let her die. It would be a simple matter to comply with her wish. I could ventilate her, and that would keep her alive. I ventilated her all the way to the hospital. Stop the resuscitation, the lawyer advised. A doctor ordered the nurse to stop. After a few minutes, it stopped entirely. The doctor pronounced her dead. Some time later, I asked a judge for an informal legal opinion on this matter.
The judge who wrote the order could have fined you or put you in jail. But no judge in this state would impose sanctions for doing what you did. It may have been illegal, but from a moral standpoint, it was the right thing to do. I think about that girl often.
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