In a small rural West Virginia community, a paramedic and his partner are called to the home of an elderly gentleman who appears to have suffered a heart attack. They’re met at the door by the patient’s frantic wife and find the patient on the living room floor surrounded by several equally frantic family members. The crew begins resuscitation efforts, but after 10 minutes the paramedic doing chest compressions decides to stop, explaining to the patient’s family that he’s not benefiting from CPR. They beg the team to continue.
IDENTIFYING THE NEED
In October 2007, there was an article published in EMS World titled, “Why EMS needs its own ethics,” by Craig M. Klugman. The article explores traditional medical ethics frameworks, which are generally used in controlled clinical settings and therefore don’t always translate well or provide useful direction in the prehospital setting. Prehospital medicine requires ethical frameworks and curriculums that address the unique situations, cases and time constraints encountered in the field.
For example, evaluating decision-making capacity, sorting through advance directives or attempting to obtain “informed” consent look much different in a patient’s living room surrounded by screaming relatives than it does in a patient’s hospital room.
Although the call for an ethics curriculum that addresses the needs of prehospital providers persists, what would such a curriculum look like?
On Nov. 14, 2011, in response to requests from within the West Virginia prehospital community, the authors of this article found themselves faced with the challenge of creating a prehospital ethics curriculum for the state’s emergency medical responders. After a review of the prehospital and bioethics literature, it became clear that little attention is being paid to developing ethics education that targets the needs of prehospital providers. Further, any available information is generally written by people who don’t work in the prehospital realm, or by providers who are working in urban settings and affiliated with large university health systems.
These observations raised concern that a generalized prehospital ethics curriculum may be inadequate for many unique prehospital settings. For example, West Virginia is a predominantly rural state, culturally diverse with great disparity in socioeconomic and educational status, and has few university-affiliated hospitals. With these concerns in mind, and in an attempt to address the specific needs of our state’s responders, we concluded that the best sources of information regarding ethical issues in the field and preferred methods of learning would be the providers themselves.
ANSWERING THE CALL
With the support of the Claude Worthington Benedum Foundation and the West Virginia Office of EMS, interviews were conducted with prehospital providers throughout the state. With an eye toward tailoring the curriculum to the unique needs of state providers, we considered literacy levels, average income, access to trauma centers and cultural diversity of those they serve, and identified eight distinct regions. We then invited emergency medical professionals from each region to participate in a semi-structured interview, during which they shared ethical issues they’d encountered in the field.
In order to be eligible to participate, providers had to have at least five years of experience including cardiac arrest and end-of-life care. The participants were given a brief survey about the amount of previous ethics education they received and their understanding of advance directives. Two-thirds of those surveyed reported having some ethics education, ranging from a day-long seminar to taking a high school ethics class. Five respondents reported that ethics was “briefly touched on in paramedic training,” two received some ethics education in the military, and one respondent’s exposure to ethics education was “only what was presented in the paramedic book.”
Participants were also asked to share the ethical issues they commonly encounter, the most ethically difficult cases they’d encountered, if they thought an ethics curriculum was needed, and how they prefer to learn (small group discussion, online or with workbooks). The interviews were recorded with permission and later transcribed to allow for a natural flow of conversation and accurate recording of the discussions.
What immediately became apparent was that these folks had a lot to say. One of the first issues mentioned by participants from all eight regions was the tension that exists between law and ethics. A primary concern was that current prehospital education prioritizes (or perhaps confuses) legal and protocol-driven decisions over ethical decisions. Participants point to the fact that any ethics education in the prehospital texts is generally nested in the legal section.
Respondents also reported that requests for assistance with ethical decision making, either from medical command or supervisory personnel, are often met with answers that address what’s legally or professionally protective rather that what’s ethically right or permissible in a particular situation.
Additionally, a good deal of variation exists between how much authority individuals and EMS crews perceive they have to make ethical decisions in the field. Some providers reported being required to run every ethically problematic situations past medical command, while others described medical command more as a resource to validate decisions made or with whom to collaboratively make ethical decisions. Others, due to practice location reasons such as problematic cell phone coverage or limited resources in a remote rural region, reported making difficult ethical decisions on their own or as a crew, often relying upon a variety of ethical frameworks such as the provider’s religious beliefs, the law, or the provider’s understanding of more commonly known ethical concepts and principles such as autonomy and informed consent.
However, across regions and disciplines, there was an acknowledgment that there isn’t a common ethics language or framework being shared between the state’s prehospital providers, let alone between other health providers.
Despite serving as the initial contact with the medical continuum of care for many patients and their loved ones, a significant number of those interviewed perceived that EMS professionals are treated professionally and environmentally separate from the rest of the medical community by both laypeople and other healthcare professionals. Some participants reported that their medical expertise is often dismissed and they’re referred to as “ambulance drivers.” The lack of ethics education routinely provided to virtually every other medical discipline seems to lend credence to their concerns. Providing EMS professionals with prehospital-specific ethics education will give them access to commonly used bioethics vocabulary and concepts, and allow them to think through ethical decisions utilizing frameworks and terms that are familiar to other health professionals, but which still speaks to their unique settings and cultures.
Providers in rural areas expressed particular interest in an ethics curriculum that would address some of their region-specific issues. Long distances to access appropriate levels of care, unique cultural issues such as snakehandling religions, and conflicts of interest and confidentiality issues that arise in small remote towns where everyone knows one another were listed as examples. With such unique challenges and limited access to medical command, rural EMS personnel requested an ethics curriculum that not only provides basic frameworks, but provides case examples and content that speak to their particular needs.
Prehospital providers generously shared their experiences and cases with us throughout the interview process. The case in the beginning of this article illustrates how important it is for EMS to have its own ethics curriculum, and for West Virginia to have a curriculum that’s further adapted to the needs of state providers. The patient was a relative of the paramedic and the paramedic was his medical power of attorney. There was only one EMS crew in town, and the nearest service was an hour away. Cases such as this don’t generally appear in prehospital texts, but they can be incorporated into state- or practice-specific curriculums (e.g., rural, urban) to reflect the experiences and needs of the prehospital professional.
With such unique challenges & limited access to medical command, rural EMS personnel requested an ethics curriculum that not only provides basic frameworks, but provides case examples & content that speak to their particular needs.
DEVELOPING THE MODEL
Overwhelmingly, small group discussion was the learning method of choice for an ethics curriculum, followed by classroom lecture with workbook and online independent learning modules. Using the information supplied in the interviews, 10 basic educational modules were developed that focus on participant-identified gaps in knowledge (e.g., informed consent). The modules consist of PowerPoint slides and corresponding cases to be used to facilitate small group discussion. Each module also has a corresponding workbook chapter and online unit, enabling providers to access ethics education in the learning format most comfortable and effective for them.
A beta module has been tested with providers throughout the state, and participant feedback will be incorporated into the curriculum. Many participants suggested these educational efforts may be more successful if medical command and designated education trainers receive similar education.
Finally, all of the survey and interview participants said they thought prehospital professionals were in need of, and would benefit from, prehospital ethics education.
The breadth and depth of the real-life experiences of these providers underscores the need, as well as the challenge, of developing a relevant and applicable ethics curriculum as the framework for this very special environment. As in every healthcare setting, evolving technology, policies and protocols, and the law create new ethical challenges. Therefore, an ethics curriculum will need to not only provide the ethics knowledge and frameworks to address current ethical issues, but will have to be adaptable and responsive to issues as they develop over time. In addition to developing a curriculum and learning formats that are relatable to the prehospital professionals of West Virginia, it’s our hope the curriculum can be adapted to meet the needs of providers in other states.
- Nordby H. (May 11, 2013.) Ethics in prehospital emergency medicine: An ethical dilemma in patient communication. Webmed-Central. Retrieved Sept.12, 2014, from www.webmedcentral.com/article_view/4247.