Tuesday, January 13, 2009

Week Two Online Challenge

Here's an online challenge on a topic we will come back to later in the course. Last week we talked about the 4 box method as a way to work through complicated ethical dilemmas. How long did it take to do one case at our first class? An hour! Will we have that kind of time in the emergency department? Of course not. But our approach right now is important to help with learning the basics. So what's next?

Kenneth Iserson is an emergency physician and bioethicist who has been writing about ethics in the ER for several decades. He has outlined a rubric for making decisions that consists of two questions:
  1. Is this dilemma a type of ethical problem for which you have already worked out a rule, or is it at least similar enough that the rule could be reasonably extended to cover the situation? (Yes? --> USE THE RULE! / No? --> Ask question #2)
  2. Is there an option which will buy you time for deliberation without excessive risk to the patient? (Yes? --> TAKE THAT OPTION! / No? --> Use a reliable reasoning technique.)
If you haven't already guessed, a primary goal of this class is to start building a set of rules that will allow you to answer "Yes!" to question 1 more often. One thing I think we should all think about, however, is:

What kind of delay tactics might be appropriate in question #2?


  1. As long as the patient isn't in immediate danger, calling for a consult can be used as both a delay tactic as well as a sounding board for you to help figure out an appropriate solution.

  2. Great idea!

    Hmmm... This is getting me thinking... How exactly would I call a consult to the ER? Details later.

    What if there were not a consult service available? Any other options for buying time?

  3. If the patient is stable and time is available to delay an answer; sit and listen to the patient. Ask open ended/probing questions to see if you can collect more information to make the decision easier. If possible state your concern(s) to the patient. Then chances are if you have given time and compassion to the patient, he/she will be willing to wait a short while why you discuss a conclusion with your mentor/attending/co-worker.

    If time is a huge factor (other demanding pts, incoming, etc.), I would seek the advice of someone with experience. Use their advice to remedy the problem and think about the issue when more time is available. Reviewing it will help cement what you want to do - even if it means next time will be different.

  4. Maintaining the patient stable enough until a decision can be made is crucial. Even after all the information is collected and the physician has prepared a plan of action, the patient may not accept help (as we saw in the case presented last week in class). I wonder if in more serious cases, perhaps internal bleeding or a ruptured organ, if the physician can morally/legally proceed with a life-saving surgery despite the patient's wishes to not proceed (cultural stigma, psych, etc.) I'll ask in class...

  5. I think the phrase "without excessive risk to the patient" should be expanded to "without excessive risk to ANY patients." Patients hang out in the ER all the time, but when other patients could be using that bed, then it becomes a question of risk to them.

    And how much time do you need for deliberation? Wouldn't that vary for each provider, based on their individual ways of making decisions, personal experiences, etc? It may not be necessary to hold the pt for hours in the ER while you "deliberate," a few seconds might be enough.

  6. It seems like the previous posts assume that the patient is stable and additional "delay tactics" are required to buy more time for deliberation. I suspect that each individual situation might have a variety of steps that could be taken to make the patient stable first. I also suspect that the range of stabilizing options will be influenced by how much time the provider(s) think they need to resolve the situation. So I would argue for a consideration of stabilizing options that take into account what might come next in the patient's treatment.

  7. Your insightful comments are getting at an important issue regarding ethical dilemmas in the ED (that may not be as relevant elsewhere). Providers must multi-task clinical and ethical decisions. So the question I think Barb is bringing up is:

    Can a clinical decision be made in order to achieve a delay for the ethical decision?