LOS ANGELES COUNTY PREHOSPITAL CODE OF ETHICS

Our EMS Community consists of a team of health care professionals including EMT-Is, paramedics, nurses, physicians, and system educators and administrators. This Code defines our ethical responsibilities and can be beneficial in guiding our practice. With regard to the following patient-oriented domains...

We believe that...
Patient Care & Patient Rights
competent medical care must be provided with compassion and regard for human dignity to all persons. we cannot allow financial considerations to influence professional judgment or quality of care. patients have the right to determine what shall be done to their body and to receive or refuse medical service, except where the patient is unable (incompetent) to make such determination. patients (or legal representatives) need to be advised of the consequences of a refusal for treatment or transportation.

Respect & Equality

regardless of nationality, race, creed, religion, sex, or status, medical services must be delivered with compassion and respect for human dignity.

Ethical Decision Making & Conflicts of Interest

we must refuse to participate in unethical activities or procedures that exceed our scope of practice. personal interests, such as economic gain, recognition, power, or promotion must not influence our provision of patient care.

Education & Competence Accountability & Confidentiality

we are accountable for providing medical care to the best of our ability and for accurately and completely documenting all patient care. in all matters pertaining to patient information and medical care, confidentiality and privacy must be respected, except where transmitting such information is necessary to deliver appropriate patient care. competence in all areas of our certification or licensure is our responsibility and is accomplished through education and training, skill practice and maintenance, and continuing education. all requirements of educational programs leading to certification or licensure must be followed. we must refrain from activities which may impair our professional judgment and ability to act competently.

Honesty & Truthfulness

patients and colleagues must be dealt with in an honest and truthful manner. it is dishonorable to participate in or cover up misconduct of a colleague and it is also wrong to harass anyone who discloses information about situations potentially harmful to the public.

Societal Obligation & Law of Practice

knowledge of prehospital care regulations and policies is necessary for optimal patient care. we have a responsibility to contribute to an improved community.

Citizenship
our EMS system, organization, supervisors, peers, and subordinates deserve our utmost loyalty. we must be loyal to the Constitution and the Government, and obey and respect the law. where conflicts of interest arise, the ultimate obligation is to the public that we serve.

Professionalism
the highest standard of professional conduct must be maintained when providing medical care. the hallmark of the professional is the willingness to do more than is required. for the benefit of the patient, members of the health care team must willingly cooperate and respect each other. colleagues lacking competence should not be misguidedly protected, but offered the opportunity for remedial action. support of prehospital care research is important to validate our practice and to promote professional growth.

Commitment
we must desire to accomplish our job in a competent manner with dedication to patient care. commitment stems from the desire to be the best one can possibly be, and the affirmation of all the preceding elements of this code.

ETHICS FOR EMS PERSONNEL

Upon completion of this unit of instruction, the student will be able to:
LEARNING OBJECTIVES
1. Define the following: A. Ethics B. Morals

LESSON CONTENT
Definition of ethics and morals: A. Ethics - Rules or standards that govern a group, profession, or individual B. Morals Social, religious or personal standards of right and wrong governed by individual conscience C. Laws Rules of conduct established by regulatory and legislative agencies Code of Ethics: Ethical codes address broad humanitarian concerns and professional conduct

NOTES / RATIONALE
Professional ethics goes beyond what a single individual thinks is right or wrong. Ethics and morals dictate personal and professional conduct.

C. Laws 2. Describe what is meant by the Code of Ethics for medical professionals.

Laws provide a narrow focus of what is right or wrong in society. Some laws may even be unethical (previous racial segregation laws). The Code of Ethics provides clear direction for avoiding ethical violations, but does not always resolve ethical conflicts/dilemmas and distress. Various professional organizations have adopted a Code of Ethics: - Physicians American Medical Association - Emergency Physicians American College of Emergency Physicians - Nurses American Nurses Association - Emergency Nurses Emergency Nurses Association - Paramedics and EMTs National Association of EMTs

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LEARNING OBJECTIVES
3. Identify to whom EMS personnel have an ethical responsibility. 4. Discuss the ethical responsibilities of EMS personnel.

LESSON CONTENT
EMS personnel have an ethical responsibility towards: Self Patients Coworkers Employer Public Ethical responsibilities: Respond to the physical and emotional needs of the patient Respect the patients wishes if possible Report accurately and honestly Respect confidentiality Maintain skill proficiency Keep current with policy and scope of practice changes. Enhance knowledge base by selfstudy and continuing education Review performance and develop improvement strategies Work collaboratively with and respect other EMS professionals

NOTES / RATIONALE
Treating a patient ethically conforms to professional standards of conduct. EMS personnel primary responsibility is to the patient.

By consistently demonstrating ethical behavior, EMS personnel gain and maintain the respect of patients and other EMS professionals. When the patient is competent and the wish is consistent with good practice, the EMS personnel is obligated to respect the patients wishes. Examples: Advanced EMS Directives (AHCD), Do Not Resuscitate (DNR), Refusal of Care and transport (AMA). Reporting care rendered accurately and honestly, even when a mistake is made, will ensure that corrective actions are taken as soon as possible. Keeping current with changes in scope of practice, enhance knowledge base and skills proficiency. This may be accomplished by attending continuing education courses, reading professional journals, and belonging to professional organizations. When faced with an ethical challenge, the question to ask in specific situations is: - Single patient - What is best for the patient? - Multiple patients What is the greatest good for the greatest number of people?

5. Discuss the prime principle of providing care.

The prime principle of providing care: First, do no harm

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LEARNING OBJECTIVES
6. Discuss four fundamental principles in making ethical decisions. A. Beneficence B. Nonmaleficence C. Autonomy D. Justice

LESSON CONTENT
Fundamental principles in making ethical decisions. A. Beneficence obligation to the patient to do good B. Nonmaleficence prevention of harm C. Autonomy respect patients wishes (right to self governance) D. Justice treat all patients fairly

NOTES / RATIONALE
Beneficence is the act of doing good where benevolence is the desire to do good. Giving the patient autonomy means allowing the patient to determine what happens to his/her own body regarding treatment. This also includes respect for the patients privacy as to imparting patient information to others and maintaining patients modesty. Treating all patients fairly means to provide the same level of care regardless of race, sex, cultural background or ability to pay. Favoritism and discrimination are unjust. Patient rights: - Right to be told the truth - Right to privacy - Right not to be injured (includes unwarranted invasive procedures such as IVs) - Right to what has been agreed upon (DNR, AHCD, etc)

7. Discuss four questions EMS personnel should apply to all patient situations.

Questions that should be applied to all patient situations: What is in the patients best interest? What are the patients rights? Does the patient understand the issue? What is the legal, professional and moral accountability of EMS personnel?

8. Discuss the following categories of ethical problems that EMS personnel may experience: A. Ethical Violations

Ethical Problems: Examples of ethical problems: A. Ethical Violations occur when EMS personnel fail to meet or neglects his moral obligation to the patient. B. Ethical Conflict/Dilemma occurs when there is a conflict of 2 or more ethical principles. C. Ethical Distress occurs when EMS personnel experiences feelings of guilt, concern or distaste. A. Ethical Violation - failure to provide competent care due to personal inconvenience can lead to legal consequences. B. Ethical Conflict/Dilemma decide which request should be honored, either the familys or the patients request. C. Ethical Distress - Provide appropriate care with insufficient equipment - Unacceptable level of infection control/self protective measures that are not available or not provided by employer - Transport patients BLS when ALS is required, etc.

B. Ethical Conflict/Dilemma

C. Ethical Distress

(CONTINUED)

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LEARNING OBJECTIVES
8. (CONTINUED) Discuss the following categories of ethical problems that EMS personnel may experience.

LESSON CONTENT
(CONTINUED)

NOTES / RATIONALE
(CONTINUED) C. Ethical Distress (Continued): - Provide care to perpetrator of a violent crime - Provide care to patients who demonstrate repeated self destructive behavior (ETOH and drug Abuse)

9. Explain what factors EMS personnel should consider in solving an ethical conflict/dilemma in the field.

Solving an ethical conflict/dilemma in the field includes all of the following factors: - Identify the problem - Ask yourself if you would undergo this procedure or action by putting yourself in the patients place (Impartiality Test) - Ask yourself if this procedure or action would be performed in all similar circumstances (Universalizability Test) - Ask yourself if this procedure or action is reasonable and would be taken by another EMS provider (Interpersonal Justification)

Resolving ethical conflicts/dilemmas is usually done by using common sense and applying rules or principles that already exist. The following steps should be used in solving an ethical conflict/dilemma: Impartiality Test - States the action in universal form. This is a version of the Golden Rule, Do onto others as you would have done onto you. Universalizability Test - Identifies the immediate and long term implications of the action. The action performed is relevant in all similar situations. Interpersonal Justification - Compares action to be taken to relevant values. Can the decision be justified to peers, supervisors, or the public? Were the basic ethical values served by the decision?

Identify the problem

10. Explain the role of the EMS community in resolving ethical conflicts/dilemmas.

Role of the EMS community in resolving ethical conflicts/dilemmas: Establish and enforce standards of care Establish treatment protocols Provide prospective and retrospective review of policies and decisions Develop QI programs and conduct research Educate EMS personnel

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LEARNING OBJECTIVES
11. Discuss specific ethical issues EMS personnel encounter.

LESSON CONTENT
Ethical issues encountered by EMS personnel: Do-Not-Resuscitate (DNR)

NOTES / RATIONALE

Advanced Health Care Directive (AHCD)

DNR Conflicts/Dilemmas: - Valid DNR, but patient is breathing and has a pulse - Familys wishes conflict with patients wishes (DNR request) - Terminating resuscitation effort when a valid DNR is presented - Personal beliefs regarding DNR requests AHCD Conflicts/Dilemmas: - Form too long and complicated - Familys wishes conflict with AHCD - Personal beliefs regarding AHCD Confidentiality Conflicts/Dilemmas: - State and federal laws (Health Insurance Portability and Privacy Act [HIPPA]) - Greatest good for patient and others - Sharing information with family members

Confidentiality

Consent

Consent Conflicts/Dilemmas: - Patient refusal of treatment/transport or specific therapies. Patients have a moral and legal right to make decisions regarding their own health. Example Patient refuses treatment such as oxygen, immobilization, etc, but wants to be transported. - Parents have moral and legal authority to make health care decisions for a child as long as the decision does not cause risk of harm or suffering. - Religious beliefs

Allocation of Resources - True parity - Need - Earned/Celebrities/VIPs

Ethics for EMS Personnel

Allocation of Resources Dilemmas: - True parity is when all patients are treated equally regardless of insurance, ability to pay, social standing, race, religion, etc. - Need MCI Triage/Government Officials ~ Civilian triage most severely injured receive the most care.

(CONTINUED)

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LEARNING OBJECTIVES
11. (CONTINUED) Discuss specific ethical issues facing EMS personnel.

LESSON CONTENT
(CONTINUED) Ethical issues encountered by EMS personnel:

NOTES / RATIONALE
(CONTINUED) - Need MCI Triage/Government Officials (Continued): ~ Military triage concentrate on least seriously injured due to need to return them to battle service. ~ Government Officials - may have an ambulance or medical personnel dedicated just for their medical needs or are treated first since they are needed to run the government. Earned/Celebrities/VIPs Dilemmas: - Should victims of violence be treated before perpetrators - Should children be treated before adults - Should celebrities be treated first to remove them from scene in order to return to normal operation

12. Explain when EMS personnel do not have a legal or moral responsibility to enter a scene and provide patient care. 13. Discuss who is responsible to enforce ethical standards.

EMS personnel are not responsible to enter a scene when: Scene is unsafe or unsecured Entities responsible for enforcing ethical standards Peers Employers Government Agencies Licensure Boards/Certifying Agencies Professional Organizations

EMS personnel are responsible to ensure scene safety for themselves, co-workers and bystanders.

Peers need to hold one another immediately accountable for inappropriate behavior. Employers, government agencies, licensure boards/certifying agencies and professional organizations need to develop and maintain QI standards and enforce ethical behavior.

Developed 9/03

Finalized 10/03

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ETHICS FOR EMS PERSONNEL

Suggested Prerequisite Modules:
Legal Aspects in Prehospital Care Well Being of the EMT/Paramedic

Basic Equipment:
None

Case Studies:
Basic Life Support Advanced Life Support

Required Student Handouts:

Los Angeles County Prehospital Code of Ethics Reference No. 815 - Honoring Prehospital Do-Not-Resuscitate (DNR) Orders. Reference No. 818 - Honoring Advanced Health Care Directives (AHCD)

Resources:
Bledsoe B, Porter R, Cherry R. Paramedic Care: Principles & Practice (Volume 1-5). Upper Saddle River, New Jersey: Brady/Prentice Hall Health, 2000. Bledsoe B, Porter R, Cherry R. Essential of Paramedic Care. Upper Saddle River, New Jersey: Brady/Prentice Hall Health, 2003. Mistovich J, Hafen K, Karren K: Prehospital Emergency Care, ed 6. Upper Saddle River, New Jersey: Brady/Prentice Hall Health. 2000. Sanders M: Paramedic Textbook, ed 2. St Louis, Missouri: Mosby Inc., 2001

On-Line Resources:
Galen Press Extras. A Rapid Approach to Ethical Problems. www.galenpress.com/extras/extra17.html Paramedic Association of Canada. National Code of Ethics. www.paramedic/ca/document/ethics.html Velasquez M, et all. Thinking Ethically: A Framework for Moral Decision Making. www.scu.edu/rthics/practicing/decision/thinking.html

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