An Industrial Accident

Emergency physicians and emergency departments serve critical public health functions at all times and particularly during public health emergencies or disasters. Public health emergencies and disasters transform standards of care into crisis standards of care. In addition to traditional tenets of bioethics, during events requiring crisis standards of care, the emergency physician faces the dilemmas of balancing responsibilities of how to allocate scarce resources to individual patients with obligations to the community and with personal and professional autonomy. Crisis standards of care permit emergency physicians to allocate scarce resources to provide necessary treatments to patients most likely to benefit. In crisis standard-of-care situations, emergency physicians must adhere to ethical and professional norms. The emergency physician should focus on how to best use the available resources with the recognition that not all patients might be able to be treated.

Risky Behavior

Patients may present to the emergency department (ED) for various complaints and requests related to risky sexual behavior. Such concerns may include pregnancy or infectious disease transmission, including urethritis, cervicitis, HIV, hepatitis, or others. Emergency physicians should test for pregnancy and infectious diseases, treat empirically for appropriate patients, and refer patients for counseling to reduce risky sexual behavior. Following a significant potential HIV exposure, postexposure prophylaxis (PEP) should be considered. The decision to administer PEP should be based on shared decision-making with the patient and should include assessment of the risk of the exposure and HIV status of the source patient. If the HIV status of the source patient is unknown, the source should be tested following informed consent and counseling. Patients should be referred to outpatient follow-up, including primary care, infectious disease, and if indicated, social services.

Frequent Flyer

Stewardship of health care resources is an important bioethical tenet of the practice of medicine. Physicians should act as stewards of resources and ensure that they are appropriately used to provide the best possible medical care for individual patients and for society as a whole. As in all cases of the physician-patient relationship, goals of therapy should be delineated, and appropriate diagnostic and therapeutic interventions to achieve that goal should be undertaken. Emergency physicians should advocate for the best treatment of the individual patient. In most cases, physician and patients agree, with the same goal of improving patient comfort and health. However, at times, there may be discordance between patient and physician. Shared decision-making should be undertaken to elicit the patient’s goals and values and then to educate and inform the patient about the physician’s recommendations. The goal is to reach a mutually agreeable course of action based on the patient’s goals and values. If unable to reach agreement, the physician should offer the tests and therapy that offer the best good to the patient.

The Drunken Drug Lord

This chapter discusses the appropriate response of emergency physicians to requests to collect evidence, in particular, blood alcohol tests and ingested drugs, from patients for police and other law enforcement officers. The relevant ethical principles, legislation, and case law are reviewed. Recommendations are made regarding when and how it may be ethically appropriate to respond to such requests.

Doctors Police Your Own Expert Witness Testimony

Experienced emergency physicians with involvement in teaching and writing about clinical topics may be approached about a case of alleged medical negligence. The physician must decide whether to get involved as a potential expert witness, subjecting oneself to the requirement for diligent and thorough review of the case in all its particulars. If one agrees to do this, one must interact with attorneys, prepare opinions, and likely give testimony in deposition, and possibly at trial if the case is not settled. Accepting the responsibility for judging whether a colleague has fallen short of the standard of care, and harmed a patient through negligence, cannot be taken lightly. Guidelines for ethical conduct by an expert witness in a medical negligence tort have been developed and promulgated by the American College of Emergency Physicians and should guide physicians’ actions.

Like, Comment, Post . . . Lawsuit?!

Social media (SM) and electronic communication (EC) use in emergency practice settings has offered patients and health care providers expansive options in accessing and utilizing information that affects medical decision-making. This widespread use has created opportunities and challenges for the health care community. This chapter discusses some of the ethical and legal ramifications of utilizing electronic communication, social media, and internet forums in patient care. The chapter seeks to prime emergency physicians and other providers to better inform themselves in order to ensure compliance with the Health Insurance Portability and Accountability Act (HIPAA) and other privacy standards. This will facilitate better patient outcomes via collaborative diagnosis while protecting against legal risks associated with the use of SM, EC, and recording for medical purposes.

Everyday J.

Commonly defined as having greater than four emergency department (ED) visits in a year, patients who are frequent users of the ED make up an estimated 3.5% to 10% of all ED visits and have been reported to account for nearly a third of all ED use. Frequent ED users have higher mortality, higher hospital admission rates, and higher use of all health care services, both specialty and primary care, compared to other patients using the ED. These patients should have the autonomy to access ED evaluation and care if he or she believes he or she has a medical emergency. This principle has been codified into both federal and many state laws protecting the “prudent layperson standard.” These patients should not be coerced to not seek ED care if the person believes he or she has an emergent condition.

Fear and Loathing in the ED: When Staff Are Afraid to Provide Compassionate Care

Opiate use disorder has a wide range of physical and social complications that often present first in the emergency department. Physiological dependence may interfere with a patient’s own attempts to detox from opiate drug use. As a result, emergency providers are faced with difficulty discerning an opiate-dependent patient’s genuine intent, especially when he or she is experiencing withdrawal. Seemingly paternalistic actions may be justified when the patient’s stated goals of “getting clean” conflict with his or her more urgent demands for opiates to end debilitating withdrawal symptoms. Individual capacity may be compromised by drug dependence. Novel approaches adapted to the emergency setting, such as medication-assisted therapy (MAT) with buprenorphine induction can help patients suffering from opiate withdrawal and mitigate conflict that may occur when patients feel undertreated by typical pharmacological approaches to withdrawal. Clinical, mental health, and legal options exist to help treat opiate withdrawal, but their applications are not without ethical dilemmas.

No Country for Sick Men

Caring for undocumented immigrants in the emergency setting brings legal and ethical challenges. This chapter discusses the spectrum of these challenges, including duty to report to immigration authorities, the restrictions placed by the Health Insurance Portability and Accountability Act (HIPAA) on ability to report, and the ethical perspective on duty to provide compassionate care for undocumented persons. Providing emergency care is mandated under the Emergency Medical Treatment and Active Labor Act (EMTALA), but coordinating care for chronic medical conditions requiring high-resource treatments may fall under the venue of emergency medicine. This chapter reviews strategies for providing chronic treatment of end-stage renal disease (ESRD) among undocumented persons, and discusses the legal and ethical questions involving this patient population.

Hide and Seek

The system of mandatory reporting was created in response to a growing recognition of devastation that child abuse was causing in the United States. All states designate people in certain professions as “mandated reporters.” This has led to discussion regarding unintended consequences or negative effects of mandatory reporting. What are our obligations toward adult patients who confide that they were abused as a child but are unsure if they want to report this now? Are we still the mandated reporters? How does patient autonomy factor into this? These laws and statutes are complex, and our legal obligations must be weighed against various ethical and practical considerations.