Resources and Educational Activities Related to Ethics and MedicineZTransport

The most important step in establishing ethics as a priority in transport is encouraging the exploration and discussion of morally challenging scenarios. Providing teams with a safe, confidential environment where questions and concerns about patient care and team function can be shared sets the frame­work for developing practices that advance the ethical and effective treat­ment of patients and their families.

Below are some hypothetical scenarios for consideration and discussion surrounding ethical precepts in transport.

Scenario One: Discussion of beneficence and nonmaleficence

A child with a devastating head injury is initially taken to a small community hospital. A team is dispatched to transport the child to the regional trauma center. On team arrival, the child is obviously moribund. The extended family has arrived and is huddled together. A ground transport would take 3 hours, and there is only room for 1 parent.

Scenario Two: Protecting confidentiality

Two teams are dispatched to a first aid station at a fairground to transport preterm twins who were precipitously delivered at a local event. There is a large group of friends and family, as well as curious onlookers, gathered at the facility, anxious for any updates. As the infants are being loaded, mem­bers of the group approach the ambulances, asking to glance at the infants and requesting an update. The care team needs to communicate about the status of the infants and details of the transport, but tearful and concerned people are surrounding the teams.

Scenario Three: Respect for autonomy—patient

A team is summoned to a rural hospital to transport a chronically ill teenager who is acutely ill.

Scenario Four: Respect for autonomy—guardians

A team is dispatched to a community emergency department to transport a child for evaluation of suspected abuse. On arrival, the parents, who are obvi­ously intoxicated, declare that they want to take the child home. They are loud and using obscenities and threaten a lawsuit if the child is not released to their care. The child is appears frightened and is begging to go home.

Scenario Five: Justice

All area transport teams are alerted of a mass casualty event involving a bus accident. Four teams are available to respond. On arrival, the teams discover 12 children and 2 adults with critical injuries. The teams must decide which patients to transport and how to manage the remaining victims during the delay.

Scenario Six: Personal integrity

A team is called to a pediatric emergency department to transfer a child sta­tus post full arrest to the tertiary care hospital for intensive care. On arrival, the child is now stable on a ventilator, but requiring support with blood pressure medications and intravenous fluids. The child is prepared for trans­port and report is taken from the referring physician and nursing team as a group. Just as the team is ready to depart, one of the nurses approaches the team and asks to speak to them confidentially. She confides that the child was stable on arrival but deteriorated as care was delayed. She communicates that the attending physician was paged numerous times but did not respond to the requests to evaluate the child. She goes on to explain that when the child became unstable, the physician finally evaluated the child but never acknowledged the delay in care or explained the lapse. She requests that this information not be shared; she simply wanted to make sure the team knew the full situation.

Selected Readings

American Academy of Pediatrics, Committee on Bioethics. Informed consent, parental permis­sion, and assent in pediatric practice. Pediatrics. 1995;95(2):314-317

American Academy of Pediatrics, Committee on Bioethics. Religious objections to medical care. Pediatrics. 1997;99(2):279-281

American Academy of Pediatrics, Committee on Pediatric Emergency Medicine. Consent for emergency medical services for children and adolescents. Pediatrics. 2003;111(3):703-706

American Academy of Pediatrics, Committee on School Health and Committee on Bioethics.

Do not resuscitate orders in schools. Pediatrics. 2000;105(4 Pt 1):878-879

Biros MH. Research without consent: exception from and waiver of informed consent in resuscitation research. Sci Eng Ethics. 2007;13(3):361-369

Cooke M, Hurley C. A case study exploring the ethical and policy dimensions of allocating acute care resources to a dying patient. J Clin Nursing. 2008;17(10):1371-1379

Diekema DS. Conducting ethical research in pediatric emergency medicine. Clin Pediatr Emerg Med. 2003;4(6):273-284

Dingeman RS, Mitchell EA, Meyer EC, Curley MA. Parent presence during complex invasive procedures and cardiopulmonary resuscitation: a systematic review of the literature. Pediatrics. 2007;120(4):842-854

Galanti GA. Caringfor Patients From Different Cultures: Case Studies From American Hospitals. 2nd ed. Philadelphia, PA: University of Pennsylvania Press; 1997

Iserson KV, Sanders AB, Mathieu D, eds. Ethics in Emergency Medicine. 2nd ed. Tucson, AZ: Galen Press; 1995

Jonsen AR, Seigler M, Winslade WJ. Clinical Ethics: A Practical Approach to Ethical Decisions in Clinical Medicine. 7th ed. NY, NY: McGraw-Hill Company; 2010

Larkin GL, Fowler RL. Essential ethics for EMS: cardinal virtues and core principles. Emerg Med Clin North Am. 2002;20(4):887-911

Pozar GD. Legal and Ethical Issues for Health Professionals. 2^nd ed. Sudbury, MA: Jones and Bartlett Publishers; 2010

Sabatino CP. Survey of state EMS-DNR laws and protocols. J Law Med Ethics. 1999;27(4): 297-315

Taveras EM, Glores G. Why culture and language matter: the clinical consequences of provid­ing culturally and linguistically appropriate services to children in the emergency department. Clin Pediatr Emerg Med. 2004;5(2):76-84

Yarrison RB, Majumder, eds. Small Group Leader’s Handbook, 2010. First Year Course in Medical Ethics, Baylor College of Medicine. Houston, TX: Center for Medical Ethics and Health Policy, Baylor College of Medicine; 2010