Medical Ethics, the Law, and Cultural Competency

Introduction

Medical ethics encompass the obligations health care professionals have to ensure patients’ overall well-being and to respect their fundamental human rights. Medical ethics applies to every healthcare provider and is a dynamic concept that varies among different societies, religious groups, and cultures. Implementing the basic principles of medical ethics is an essential component of patient care. There are four main pillars of medical ethics:

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Autonomy: Allow an individual freedom to make their own decisions.
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Justice: Treat all patients fairly and with equality.
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Beneficence: Do good on behalf of the patients and society as a whole.
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Nonmaleficence: Do no harm or protect from harm.

The four main pillars of medical ethics serve as a general guide in patient care and are adaptable to specific situations. There are inherent limitations to each of these principles. For example, autonomy may not be appropriate for a patient who lacks decision-making capacity due to severe dementia or intoxication.

These concepts not only dictate standards of care but also help us evaluate our own personal biases and behavior toward patients, their families, and our colleagues. Consider the concept of cultural sensitivity and how that fits into the pillars of medical ethics. In the ED, we often encounter patients of varied religious, cultural, and social backgrounds. Respect, professionalism, and consideration of such differences are imperative in implementing patient-oriented care in hopes of improving patient outcomes.

Everyone on the medical team should ensure that the patient’s well-being is a priority during the ED visit and has an obligation to speak up with concerns or questions. Technicians are especially important in this process because they often have more frequent interactions with patients and their families and can provide an invaluable perspective.

Emergency Medical Treatment and Labor Act

Providing emergent, stabilizing care to all patients regardless of financial considerations is required by a Federal law called the Emergency Medical Treatment and Labor Act (EMTALA). EMTALA requires that all patients presenting to the ED receive a “medical screening exam” to ensure that the patient’s complaints do not represent a life or limb threatening emergency. Patients then must receive whatever care the hospital can provide to treat and stabilize their condition.

Prior to the passing of EMTALA, patients were occasionaly turned away from hospitals unless the patient had a certain type of insurance or could pay for the treatment. This often resulted in patients being moved from private to public hospitals even if the private hospital could provide the needed treatments. A hospital may transfer a patient to another medical facility for higher level of care, such as trauma surgery or interventional radiology if those services are not provided at the original hospital. Additionally, EMTALA requires that larger, referral hospitals must accept transfer patients from less equipped hospitals if the referral hospital has the facilities required to treat the patient experiencing the emergency. The receiving facility cannot refuse such a transfer for financial reasons.

Health Insurance Portability and Accountability Act

Patient privacy is essential to fostering a safe and autonomous healthcare environment. Personal medical information and history is sensitive information that should be treated as such. The Health Insurance Portability and Accountability Act (HIPAA) protects the privacy of patients by describing with whom a patient’s medical information can be shared. The purpose of HIPAA is to limit the distribution of protected health information (PHI) on a need-to-know basis. When providing care to patients, all members of the care team should be informed of the patient’s condition and relevant medical history. Members of the care team are authorized “need-to-know” individuals.

PHI is any information that links a medical condition to an individual. Information such as a name, date of birth, address, and contact information are all considered PHI. HIPAA prohibits the sharing of PHI in written, spoken, and electronic formats. The majority of health information is stored electronically, so it is imperative that necessary practices are in place to protect patient privacy. Keeping computers locked when not in use, not sharing passwords, and employing encryption are the most common and effective methods to protect electronic patient information. Never share information about the patient outside of their treating healthcare team without patient consent. This includes not discussing specific patient issues with colleagues in public places such as hospital elevators or cafeterias and not sharing information with family members who are not the patient’s designated guardian or surrogate.

Three Cs: Consent, Capacity, Competence

There are times when a patient’s ability to consent to a procedure or specific care plan is unclear. For example, consider an elderly patient who has advanced Alzheimer dementia arriving at the ED for syncope and is later found to have advanced renal failure. The patient is in need of emergent hemodialysis and placement of a central line for access. How would a provider determine the patient’s capacity to consent for the procedure while also respecting their autonomy?

A defiinition of the three c’s includes: ( Fig. 22.1 ):

Consent: A process in which an individual agrees to a particular procedure/treatment
Capacity: A measure of someone’s ability to make a decision about a particular procedure/treatment, including an understanding of the risks, benefits, consequences, and alternative treatment options
Competency (legal term): An individual’s ability to consent to a particular procedure/treatment being offered

Consent, capacity, and competency are specific to a particular situation and can change from one moment to the next. Additionally, assessing a patient’s capacity is needed to determine their competency. For example, a patient with dementia may be able to decide between chocolate and vanilla ice cream but might not have the capacity to make decisions regarding complex medical issues. Determining capacity can be complex and is often performed by an attending physician, advanced practitioner, and/or psychiatric team.

Against Medical Advice

Patients may choose to leave the ED against medical advice (AMA) for many reasons, such as prior obligations, family commitments, dissatisfaction with care, fear, frustration, and miscommunication. They may refuse further treatment or specific treatment plans, medications, evaluation, or other aspects of patient care. Although these situations can be frustrating and time-consuming, respecting patients’ autonomy while balancing legal and ethical considerations is important.

Patients who leave AMA are at increased risk for readmission and mortality and thorough documentation on these patients is a must. The ED tech should ensure that any notes they make on the patient are consistent with those made by the RN’s and providers.

If a patient chooses and has the capacity to decide to leave AMA, it is imperative that several steps be taken to protect the patient and providers.

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Ensure that the patient is aware and understands the risks of leaving AMA. Most institutions have an AMA form for the patient and a witness to sign. In addition to completing the form, it is worthwhile for the provider to include a comprehensive narrative in the patient’s chart that describes the provider’s concerns, notes that they have the capacity to refuse treatment, and details the efforts they made to dissuade the patient from leaving.
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Remove the patient’s intravenous (IV) line, and allow them to dress in their own clothes.
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Provide the patient with discharge instructions, including a statement that they are encouraged and welcome to return to the ED at any time.

When a patient decides to leave the ED prior to discharge and without going through the process of AMA counseling, it is called elopement .

Hospice and Palliative Care in the Emergency Department

The EDT will be treating many patients with serious illness in the ED, and these patients may benefit from palliative care. The word palliate means “make a disease or its symptoms less severe or unpleasant without removing the cause.” The objective of palliative care is to aggressively treat disease symptoms in order to minimize the patient’s suffering in the setting of serious or incurable illness ( Table 22.1 ). Palliative medicine addresses the biological, psychological, social, and spiritual pain that patients experience. This type of care can be instituted in the ED and then continues in the inpatient setting or as an outpatient after being discharged.

Table 22.1

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