CHAPTER 37. Ethical Issues

Reneé Semonin Holleran

Competencies

1. Identify ethical issues related to patient transport.

2. Describe a framework for ethical decision making.

3. Participate in the development and implementation of protocols for “no patient transport.”

Many of us went through our professional training with limited exposure to ethical decision making. Then, we went through training that persuaded us that we could save everyone. So, when we have to make difficult transport decisions, we have to do it based on previous experience or with use of preestablished protocols whose development we may or may not have been allowed to participate in.

Today, transport team members are faced with many ethical dilemmas, including who to transport, when resuscitation is futile, and the use of technology. One of the most commonly faced dilemmas by all transport teams is when not to transport a patient. Research has documented that the outcomes of patients who sustain cardiac arrest before reaching the hospital are dismal, and patient transport is expensive. ^2.^3.^4.^5.^6.^7.^8.^{and 9.}^11,¹⁷ Currently, transport programs make “no-transport” decisions on the basis of a number of factors.

Other ethical challenges may include being asked to transport patients in unsafe environments, for example, when the weather is less than optimal. Some transport teams are forced to make decisions about whether to transport a patient with equipment or problems that they have inadequate experience handling because of competition or fear of revenue loss.

This chapter offers an example of a framework that may be used to make ethical decisions. It also contains information about a common problem encountered in the transport environment: to transport or not to transport. The case study at the end of this chapter provides an outline that may be used to generate discussion about ethical problems that may be encountered by the transport team.

ETHICAL DECISION MAKING IN THE TRANSPORT ENVIRONMENT

Ethical decisions are generally made based on a set of specific values, which include^1,¹⁰:

▪ Patient autonomy: Allowing patients to make decisions about their healthcare.

▪ Beneficence versus malfeasance: The benefit of the transport outweighs the potential harm the transport could cause.

▪ Veracity: Honesty, telling the truth, open patient care and healthcare provider relationships. Veracity should also extend to statement of purpose for the transport program.

▪ Justice: Fairness for the patient and, at times, the community that the transport program serves.

The American Nurses Association¹ has provided a Code of Ethics for Nurses for decades. The most recent version offers a framework on which a nurse may practice. Concepts expressed include:

▪ Nurses must practice with compassion and respect for the inherent dignity, worth, and uniqueness of every individual unrestricted by their diversity.

▪ A nurse’s primary commitment is to the patient.

▪ Nurses must strive to protect the health, safety, and rights of the patient.

▪ Nurses are responsible and accountable for their nursing practice.

▪ Nurses owe the same duties to themselves as to their patients to preserve integrity and safety, maintain competence, and continue personal and professional growth.

Nursing is involved nationally and internationally in the shaping of social policy and in efforts to meet healthcare needs.

Examination of these values is important when making decisions about patient care in the transport environment. Unfortunately, multiple demands may influence the transport decision, including competition, lack of experience, and concern about employment.

The availability of equipment, advanced life support skills, and personnel has contributed to the development of a technologic imperative. ^5,¹⁰ In other words, because we have it, we must use it. Patients, families, and communities have come to expect that everything is available for everyone.

Iserson and colleagues¹⁰ have developed a model that can be used to make ethical decisions in the transport environment. This model includes:

▪ Problem perception: Is there a problem?

▪ List alternatives: Identify solutions and barriers.

▪ Choose an alternative.

▪ List the consequences of the actions chosen.

▪ Consider one’s own personal beliefs when making the decision.

▪ Evaluate the decision.

Ethical decision making is a dynamic process. The transport team cannot ignore previous experience or the personal beliefs of the team members and those with whom the team is working. These things are never easy, but they cannot be overlooked.

TO TRANSPORT OR NOT TO TRANSPORT

As healthcare costs continue to increase, the cost of patient transport and appropriate use of services have become important issues that many transport programs must address. Deciding when to transport patients who have sustained cardiac arrest, whether as a result of trauma or a medical problem, continues to be one of the most difficult dilemmas faced by many transport programs. Research has shown that survival rates of patients who have out-of-hospital cardiac arrests range from 1.9% to 5%. Many survivors sustain severe neurologic injury, and the quality of their life is impaired. ⁹^–¹⁸

Data from a 10-year period of transport of patients who needed cardiopulmonary resuscitation during air medical transport indicated that only 1.9% of these patients survived. The injuries sustained by the patients ranged from those from motor vehicle crashes to gunshot wounds to the head. The only intervention provided by the flight team that was not provided by emergency medical services was the administration of blood. The average cost of each flight was $2671. ⁸

In a study from the University of Louisville, ⁹ researchers found that six patients (2.4%) of patients with traumatic arrest survived. The air medical costs for these patients averaged $2600. The researchers concluded that patients with cardiac arrest who have obvious severe brain injury and those who have been in arrest for longer than 30 minutes should not be resuscitated. ⁹

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