Explore

Ethical Issue

Narrative

In the ER, at 17:00 in the evening, we had just received a referral of a 79-year-old woman who arrived with her daughter, reports of palpitations, and an ECG in hand. The doctor on call asked me what I thought of the ECG she arrived with. Having just revised ECGs, I quickly concluded that she had AF with rapid ventricular conduction, and proceeded to go over an approach to the various types of tachycardias with the younger medical and nursing students. During this, we heard her daughter shouting from across the room. Her mom had chest pain again and was going limp. I felt her, and she was already cold.

She was destabilizing. Most likely cause: conversion to a ventricular arrythmia. I yelled to get the ECG and defibrillator to assess whether she was shockable, but the young doctor on call said to leave it, as she didn't know how to use it. Instead, she suggested the patient had beta-blocker toxicity from the propranolol given an hour ago. This shattered me, beta blocker toxicity is far from likely (odds as low as 3-5%), meaning that either way, we should do an ECG to confirm. If it's fast, it's a tachyarrythmia. If it's slow, it's more likely to be beta-blocker toxicity. Nellie and I ran to the resus station to grab the high-tech defibrillator and ECG machine that had been donated by a German NPO, which had failed to teach the staff how to use either, choosing instead to write the cheque, take the necessary pictures for social media, and leave.

We quickly searched for the model online and found the instructions for its use. Wheeling it through to the patient’s bed in the ER as we did so, we pushed through an ever-growing crowd of nursing students, just standing around watching. This ER does not have many emergencies: trauma and violence rates are incredibly low because of the country’s zero tolerance for crime and social discord, smoking, drugs, drunkenness, or community justice. Their medical emergencies are also limited due to their incredibly healthy lifestyles. Rwandans don't have access to fast food (there's one KFC in the whole of Rwanda, and even it has been crippled by the authorities banning some crucial chemicals in their famous ‘secret recipe’ for public health’s sake). They ride or walk pretty much everywhere (and Rwanda is called the ‘country of a thousand hills’ for a reason – you’ll struggle to find a flat section longer than 20 metres, so everybody is walking or cycling uphill and downhill on repeat, strengthening their cardiovascular fitness and skeletal muscle). In short, there are very few strokes, heart attacks, DKAs, assaults, or patients with COPD, which take up the majority of emergency resources in South Africa.

The downside of this, of course, is that, when there is an emergency, most people stand around, as these doctors/nurses were doing. Back to the story: with Nellie and I frantically following online diagrams to place the six ECG stickers in the correct locations, our patient lost a pulse. So, we climbed in with repeated rounds of CPR—most doctors and nurses doing less than 30 compressions before providing two breaths that escaped out of the side of the mask because they hadn't lifted the patient’s airway. After showing the lead nurse how to bag, I jumped in with compressions, feeling this frail old lady’s ribs crack with each successive shift. Eventually, after Nellie got our ECG up and running—17 minutes into resus—we got a read on the rhythm: broad regular tachycardia. V-fib. All she needed was a shock. Before anyone could figure out how to charge the machine to 200J (according to SA guidelines), she’d slipped back into asystole. Ten minutes later her pupils were fixed and dilated. “Damn.”

I looked up and saw a crowd of nursing students, ER patients, and doctors standing around, with zero privacy for the patient. Next to them was the patient’s daughter, wide-eyed, having witnessed the whole thing. She burst into tears as I, the medical student, called my first time of death. The jury is out as to whether an earlier shock would have saved her, but I went home with a bitter taste, knowing that we could have done better. I learned the value of knowing how equipment works, of emergency algorithms, and some hard lessons about working with new people in a new environment without much experience. We debriefed, and I raised to the clinical supervisor that we need to do ECG training with everyone as soon as possible. Nellie and I had thought it was slightly humorous when we came in on day one and had to show the nurses how to do a 12-lead ECG. It wasn't funny anymore.

⁠

Ethical Analysis using the 5 step process taught in our lectures

1. Identify & Articulate Ethical Dilemma

Ethical Dilemma: The ethical dilemma arose when a 79-year-old female patient with known atrial fibrillation (AF+) and rapid ventricular response presented to the Emergency Room (ER) with chest pain and destabilizing vital signs. As the first responder, I recognized the urgency of the situation and immediately requested the ECG and defibrillator to assess whether she was shockable. However, the doctor on call advised against using the equipment, citing unfamiliarity with its operation and suggesting beta-blocker toxicity as the cause of her deterioration. Faced with this directive, Nellie and I took the initiative to retrieve and operate the defibrillator and ECG machine, despite lacking formal training. Our attempts to administer life-saving interventions were unsuccessful, resulting in the patient’s death.

Core Ethical Issues:

Resource Allocation and Fairness (Justice): The presence of advanced medical equipment without adequate training for all staff members created an inequitable situation.

Intent to Do Good (Benevolence): The immediate actions taken by Nellie and me were driven by a genuine desire to save the patient’s life.

Avoiding Harm (Non-Maleficence): Delays and improper use of medical equipment may have contributed to the patient’s adverse outcome.

Respecting Patient Autonomy: The lack of privacy and proper communication during the emergency compromised the patient’s dignity and the family’s ability to provide informed consent.

⁠

2. Gather Information

Incident Details:

Patient Information:

Name: [Anonymized]

Age: 79

Condition: Atrial Fibrillation (AF+), Rapid Ventricular Response

Presentation: Chest pain, destabilizing vital signs, cardiac arrest

Clinical Context:

Location: Emergency Room, Kibogora Hospital, Rwanda

Resources: High-tech defibrillator and ECG machine donated by a German NPO

Staff Training: Limited training on new equipment; young doctor unfamiliar with defibrillator usage

Environment: Low frequency of severe emergencies; high prevalence of minor medical issues

Actions Taken:

Initial Response: Requested ECG and defibrillator

Directive from On-Call Doctor: Do not use equipment; suspect beta-blocker toxicity

Immediate Action by Nellie and Me: Retrieved and attempted to operate defibrillator and ECG using online instructions

Outcome: Patient did not survive despite interventions

Supporting Factors:

Donation Without Training: Equipment provided without comprehensive training for staff

Cultural and Environmental Factors: Low incidence of severe emergencies leading to complacency in emergency preparedness

Emotional Impact: Witnessing the patient’s death and the family’s distress

⁠

3. Analyze Data

Application of Ethical Principles:

Justice:

Issue: The equitable distribution of medical resources was compromised as only a few staff members were trained to use the donated defibrillator and ECG machine.

Impact: This created an unfair situation where the ability to provide life-saving interventions was limited to those with specific knowledge, disadvantaging both patients and the majority of the medical team.

Benevolence:

Issue: Nellie and I acted with the intention of benefiting the patient by attempting to use the defibrillator and ECG to save her life.

Impact: Our actions were motivated by a genuine desire to help, but the lack of training and support hindered our effectiveness, ultimately failing to achieve the intended good.

Non-Maleficence:

Issue: The delay in providing appropriate emergency care due to insufficient training and reliance on untrained staff may have contributed to the patient’s adverse outcome.

Impact: The potential harm caused by improper use of medical equipment and delayed interventions highlights a breach in the duty to avoid causing harm.

Autonomy:

Issue: The public nature of the resuscitation attempt and the lack of privacy compromised the patient’s dignity and the family’s ability to provide informed consent.

Impact: Respecting patient autonomy involves maintaining privacy and ensuring that patients and their families are informed and involved in care decisions, which was not adequately upheld in this situation.

Identified Ethical Failures:

Inadequate Training and Resource Management (Justice)

Ineffective Emergency Protocols (Non-Maleficence)

Compromised Patient Dignity (Autonomy)

⁠

4. Develop Policy

Proposed Policy Solutions:

Comprehensive Training Programs:

Objective: Ensure all medical staff are proficient in using donated medical equipment.

Implementation: Organize regular training sessions and workshops for all staff members upon the introduction of new medical devices.

Responsibility: Hospital administration in collaboration with the donating organizations should mandate and facilitate training programs.

Standardized Emergency Protocols:

Objective: Develop and implement clear, standardized protocols for handling medical emergencies.

Implementation: Create detailed guidelines for emergency response, including the use of medical equipment, roles of team members, and steps for rapid intervention.

Responsibility: Establish a committee to draft, review, and disseminate emergency protocols, ensuring all staff are familiar with them through drills and assessments.

Equitable Resource Allocation:

Objective: Ensure fair distribution and accessibility of medical resources across all departments and staff levels.

Implementation: Conduct regular audits of medical equipment distribution and usage, ensuring that all departments have the necessary tools and training to provide optimal patient care.

Responsibility: Hospital administration should oversee resource allocation and ensure transparency and fairness in the process.

Enhancing Patient Privacy and Autonomy:

Objective: Protect patient privacy and uphold their autonomy during medical procedures and emergencies.

Implementation: Designate private areas for resuscitation efforts and train staff on the importance of maintaining patient dignity and confidentiality.

Responsibility: Incorporate privacy considerations into hospital layout planning and emergency protocols, ensuring that patient autonomy is respected at all times.

Continuous Ethical Education:

Objective: Foster an ethical culture within the healthcare team.

Implementation: Provide ongoing education on medical ethics, emphasizing the principles of justice, benevolence, non-maleficence, and autonomy.

Responsibility: Incorporate ethics training into regular professional development programs for all healthcare staff.

⁠

5. Implement Policy

Action Plan for Policy Implementation:

Organize Training Workshops:

Timeline: Within the next three months

Steps:

Schedule training sessions with equipment manufacturers or trained professionals.

Ensure mandatory attendance for all relevant staff members.

Conduct assessments post-training to verify proficiency.

Develop and Disseminate Emergency Protocols:

Timeline: Within the next two months

Steps:

Form a committee comprising senior medical staff and administrators.

Draft comprehensive emergency protocols.

Distribute protocols to all departments and conduct training drills.

Audit and Monitor Resource Allocation:

Timeline: Ongoing, with initial audit within the next month

Steps:

Conduct an inventory of existing medical equipment.

Assess the distribution and accessibility of resources.

Adjust allocations based on audit findings to ensure fairness.

Redesign ER Layout for Privacy:

Timeline: Within the next six months

Steps:

Evaluate the current ER layout and identify areas lacking privacy.

Collaborate with architects or planners to redesign private resuscitation areas.

Implement changes and ensure all staff are trained on maintaining patient privacy.

Integrate Ethical Education into Professional Development:

Timeline: Ongoing, with first session within the next month

Steps:

Develop an ethics curriculum tailored to the hospital’s needs.

Schedule regular ethics workshops and seminars.

Encourage reflective practice and discussions on ethical dilemmas.

Monitoring and Evaluation:

Regular Feedback: Collect feedback from staff on training effectiveness and protocol clarity.

Performance Metrics: Track response times and outcomes of emergency cases post-implementation.

Continuous Improvement: Use feedback and performance data to refine training programs and protocols continuously.

Ethical Audits: Conduct periodic ethical audits to ensure adherence to the established policies and principles.

Want to print your doc?
This is not the way.

Try clicking the ⋯ next to your doc name or using a keyboard shortcut (

CtrlP

) instead.