Ethical Dilemmas That May Occur During the Referral, Triage, or Care Periods

Ethical dilemmas may occur related to the consequence of transporting or not transporting the pediatric patient. Triage decisions regarding the avail­ability and type of facilities available to care for the patient after transport brings forward the issues of justice.

Medical information is considered private, and personal health infor­mation is protected by law. Careless or inadvertent revealing of identifiable information are risks that transport team members face, as they frequently care for ill or injured people in a public environment. Team members have a fiduciary responsibility to protect and promote a patient's health related interests. Moreover, there is an ethical appeal to the duty of respect and sensitivity for the patient's vulnerability. It is essential that transport team members remain aware of the potentially sensitive nature of identifiable information and take every possible precaution as they care for patients, including children. Sensitive discussions should, when possible, occur where bystanders cannot overhear them. The use of last names should be avoided if possible at the scene. Private information should not be shared with any other than those legally responsible for the patient. Finally, because radio communication systems may be monitored, use of names should be avoided unless absolutely essential to the receiving hospital. If use of names is impor­tant, then a telephone should be used at the scene rather than a radio.

A particularly challenging situation occurs when transport team mem­bers are faced with parents or a legal guardian who refuses to give permission for further medical treatment or transport of a child or are mentally inca­pacitated (eg, intoxicated).

The American Academy of Pediatrics has clearly stated that physicians should be prepared, “to seek legal intervention when parental refusal places the patient at clear and substantial risk.” Such circumstances require that the transport team notify on-site or online medical control for guidance. The medical control physician might speak directly with the legal guardian. When the legal guardian still refuses to consent to medical care or transport that is necessary to prevent death, disability, or serious harm to the child, it is both legally and ethically appropriate to notify social service agencies and/or the court to intervene under local and state child abuse and neglect laws as the child may need to be placed in temporary protective custody. Likewise, when parents or a legal guardian seem to be intoxicated or oth­erwise impaired, involvement of law enforcement officers or the court may be necessary. In these rare situations, the hospital attorney or legal office at the referring and receiving facilities also should be notified after the safety of the child has been ensured.

Although temporary protective custody may allow the transport team to transport a minor to a medical facility for purposes of further emergency medical evaluation and care, it does not give medical professionals the right to treat a minor for medical conditions that are not serious or life threaten­ing. A medical professional can provide medical treatment without consent only when the child has a medical condition that poses a risk of death or serious harm, when immediate treatment is necessary to prevent that harm, and when only the treatments necessary to prevent the harm are provided.

In the aforementioned situations, team members should attempt to establish whether the caregiver refuses all care and transport or only certain aspects of care. One should also evaluate the ethical tenets that may under­lie those refusals. General moral constraints, such as opposition to forms of medical treatment because of religious tradition, may play a role (eg, refusal of blood transfusion by Jehovah's Witnesses), as can language barriers. Although language barriers are usually thought of as 2 different languages and the misunderstanding that can occur when people do not have fluency in each language, lack of health literacy may result in the family and/or the patient not understanding the need for medical care and transport of the patient. Written patient information materials must be written at a level (4th to 6th grade) to enhance comprehension. Miscommunications can have a significant effect on a child's care, especially if transport team mem­bers are unable to obtain information about a child's underlying medical conditions, allergies, current medications, and other relevant and important information. Transport team members should be familiar with the resources locally available to provide professional translation and interpretation in a timely manner. If such services are not available, a family member or neigh­bor might be available to assist with a rough interpretation. Transport team members should be aware, however, that the interpretation may not be accu­rate when a trained interpreter is not used.

If all attempts at improving communication are unsuccessful and the child can be transported safely without initiating care, the parent's or guardian's wishes concerning treatment may be respected. It also may be appropriate for the caregiver of a child with a terminal illness or significant disabilities to restrict or request certain kinds of care for the child, thus invoking the concepts of beneficence and nonmaleficence.

On rare occasions, parents or guardians may disagree among themselves whether to consent to treatment and transport of a sick or injured child. In these cases, it is important to establish whether one or both has legal decision-making authority on behalf of the child. Because state laws vary with regard to the legal authority of the father when parents are unmarried, transport team members should be familiar with state and local laws that govern this situation. If both caregivers have legal authority, transport team members may need to negotiate a plan that is acceptable to both and respects the rights of all. Focus should be on the child's needs and the ethical goals of compassion and self-sacrifice to assist the child. Self-sacrifice in this context would mean taking a risk to the caregivers own self-interest in terms of time spent and convenience to protect and promote the interest of the patient. This strategy can deflect attention away from the disagreement and may be successful in resolving the issue.

To respect the autonomy of others, transport team members should always remain nonjudgmental and respect those requests that may stem from cultural or religious beliefs. They should acknowledge the importance of these requests, and attempt to accommodate them when they do not pose a risk to the child. When the transport team cannot accommodate requests that are based on cultural or religious beliefs because they would put a child at risk of serious harm, they should respectfully explain the reasons for being unable to accommodate the requests.

One of the most difficult ethical situations involves the patient who is terminally ill. If there is a do-not-resuscitate (DNR) order in place, signed by a physician, it informs the provider that cardiopulmonary resuscitation should not be initiated or should be of limited scope in a cardiopulmonary arrest. Only some jurisdictions recognize prehospital DNR orders as valid for children. It is very important that transport team members clarify the lim­its of the DNR laws governing their service areas and develop protocols for dealing with them.

may not. Discussion with on-site and online medical control and consultants may help transport personnel deal with these issues.

In the course of stabilizing the patient prior to transport, resuscitation may be required. The wishes of the surrogate decision maker will usually guide the extent and duration of the process. To maintain professional and personnel integrity as well as a respect for the patient, local resuscitation policy should define circumstances when cardiopulmonary resuscitation should be initiated, when it may be withheld, and when it may be stopped. If resuscitation is ineffective or not indicated (ie, the patient is clearly dead), it is ethically permissible to stop or not initiate the process. For pediatric cases, the policy should favor resuscitation in questionable cases, but allow appropriate withholding of resuscitation to focus on grief management and family interaction. This may be emotionally difficult for transport team members, but the aforementioned ethical precepts of integrity and respect as well as the virtue of honesty should guide their actions.

The practice of allowing family members to be present during resus­citation remains somewhat controversial. However, available data over­whelmingly suggest that families want to be given the opportunity to be present for the resuscitation of a child or loved one, that they do not interfere with the staff, that staff do not feel excess stress when family members are present, and that family members may deal with grief in a more healthy manner if they were present during a resuscitation attempt after which a loved one died. Families are also reassured that everything was done for their child that could be done. Therefore, family members should be given the opportunity to be present during resuscitation and transport, if they desire and it does not interfere with patient care (see Chapter 12). Having a dedicated staff person identified and available to support family members during resuscitation is helpful and recommended.