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Original article
Moral experience and ethical challenges in an emergency department in Pakistan: emergency physicians’ perspectives Waleed Zafar ▸ Additional material is published online only. To view please visit the journal online (http://dx.doi.org/10.1136/ emermed-2014-204081). Correspondence to Dr Waleed Zafar, Department of Emergency Medicine, Aga Khan University, Stadium Road, P.O. Box 3500, Karachi 74800, Pakistan; [email protected] Received 6 June 2014 Revised 1 August 2014 Accepted 15 August 2014 Published Online First 18 September 2014
ABSTRACT Introduction Emergency departments (ED) are often stressful environments posing unique ethical challenges —issues that primarily raise moral rather than clinical concerns—in patient care. Despite this, there are very few reports of what emergency physicians find ethically challenging in their everyday work. Emergency medicine (EM) is a relatively young but rapidly growing specialty that is gaining acceptance worldwide. The aim of this study was to explore the perspectives of EM residents and physicians regarding the common ethical challenges they face during patient care in one of only two academic EM departments in Pakistan. These challenges could then be addressed in residents’ training and departmental practice guidelines. Methods A qualitative research design was employed and in-depth interviews were conducted with ED physicians. Participants were encouraged to think of specific examples from their work, to highlight the particular ethical concerns raised and to describe in detail the process by which those concerns were addressed or left unresolved. Transcripts were analysed using grounded theory methods. Results Thirteen participants were interviewed and they described four key challenges: how to provide highest quality care with limited resources; how to be truthful to patients; what to do when it is not possible to provide or continue treatment to patients; and when (and when not) to offer life-sustaining treatments. Participants’ accounts provided important insights into how physicians tried to resolve these challenges in the ‘local moral world’ of an ED in Pakistan. Conclusions The study highlights the need for developing systematic and contextually appropriate mechanisms for resolving common ethical challenges in the EDs and for training residents in moral problem solving.
INTRODUCTION
▸ http://dx.doi.org/10.1136/ emermed-2014-204252
To cite: Zafar W. Emerg Med J 2015;32:263–268.
Emergency departments (ED) are often stressful environments where emergency physicians and nurses manage acutely ill patients under resourceconstrained and time-constrained circumstances. Work under such circumstances can pose unique ethical challenges in patient care—issues that primarily raise moral rather than clinical concerns. These challenges include management of patients who may or may not be in a position to give informed consent,1 2 the need to maintain patient privacy and confidentiality in a disordered space,3 dealing with requests to provide treatment of no clinical benefit4 5 and discussing sensitive and difficult decisions regarding end of life with patients and families.6 Moreover, the time needed for
Key messages What is already known on this subject? ED physicians in an ED in Pakistan reported facing frequent ethical challenges in their everyday practice which require moral, in addition to clinical, decision-making. Available resources were viewed to be of limited help, and little formal training was given on how to handle these issues. What might this study add? There is a need for developing systematic and contextually-appropriate mechanisms for resolving common ethical challenges in low-resource EDs and for training residents in moral problemsolving.
dispassionate analysis of facts and application of moral reasoning suggested for clinicians may not be available to ED physicians.7–9 Despite this, there are very few reports of what emergency physicians find ethically challenging in their everyday work.10 Emergency medicine (EM) is a relatively young but rapidly growing specialty that is gaining acceptance worldwide.11 12 It is, therefore, especially important to understand what moral challenges emergency physicians face and to think about how best to resolve them. Unresolved moral challenges can lead to moral distress—painful feelings that occur when the healthcare provider does not know what the morally right thing to do is or, because of institutional constraints, is unable to act according to his or her moral judgment—and is associated with low job satisfaction, staff turnover, physician burnout and poor patient care.13 14 The aim of this study was to explore the perspectives of EM residents and physicians in one of only two academic EM departments in Pakistan regarding the common ethical challenges they faced during patient care. In exploring the physicians’ perspectives, the study primarily drew on Arthur Kleinman’s theory of ‘moral experience, or what is at stake for actors in a local moral world’ (ref. 15, p.1525). In conceptualising ED as a ‘local moral world’, this study focused on physicians’ ‘lived’ experiences trying to balance the moral demands of their profession and the variety of constraints under which they operate.16 Consequently, the aim was neither to evaluate physicians’ understanding of bioethical principles, vocabulary or discourse, nor to illustrate ethical challenges in EM that may be universally relevant. Instead, the goal was to understand, in physicians’ own words, the situations
Zafar W. Emerg Med J 2015;32:263–268. doi:10.1136/emermed-2014-204081
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Original article Table 1 A comparison of the study site with some of the other large hospitals in Karachi, Pakistan
Hospital
Sector
Aga Khan University*
Private non-profit
Liaquat National
Private non-profit
Civil Karachi
Public
Jinnah Postgraduate Medical Centre
Public
Abbasi Shaheed
Public
Approximate number of providers in ED per day (all shifts included)
Approximate number of patients seen per day in the ED
Approximate total number of beds in the hospital
35–45 physicians; 45–55 nurses 20–25 physicians; 45–50 nurses 15–25 physicians; 20–30 nurses 25–30 physicians; 20–35 nurses 25–35 physicians; 50–60 nurses
200–250
600
Yes
180–220
700
No
900–1200
1900
No
900–1200
1300
No
900–1200
850
No
Provides graduate training in EM
*Study site. ED, emergency department; EM, emergency medicine.
or circumstances that they find ethically challenging in their local cultural, economic and clinical context.
METHODS Setting and context Semistructured in-depth interviews were conducted with EM residents and physicians working in an academic EM department and ED in a teaching hospital in Karachi, Pakistan. This site, a private non-profit hospital that serves about 200–250 patients per day in its ED, was selected because it is one of only two programmes to offer EM residency training in Pakistan. The residency programme follows an indigenously developed EM curriculum that is approved by the College of Physicians and Surgeons of Pakistan, and is closely based on the guidelines by the US Accreditation Council for Graduate Medical Education. A comparison of the study site with some of the other large hospitals in Karachi is presented in table 1. For a brief note on the health system in Pakistan and the emergency care landscape in Karachi, please see the online supplement. The aim of the study was to understand common ethical challenges faced in the ED that can then be addressed in residents’ training and departmental practice guidelines.
Data collection and analysis An interview guide (box 1) was developed to understand in detail emergency physicians’ perspectives on the common ethical challenges they faced during clinical work. Initial version of the guide was tested with three residents. Physicians working full-time in the ED and senior (3rd and 4th year) residents in the EM residency programme were considered for inclusion in this study. Purposive sampling was used to assure adequate representation of perspectives from various training tracks and in terms of gender and years of clinical experience.17 Enrolment was continued until saturation of key themes.17 18 The interviewer, a full-time physician-researcher with no training in EM, began by reading to the participants a generic definition of ‘ethical challenge’ and ‘ethical dilemma’ and then asked nine open-ended questions about common ethical challenges faced in the ED. Participants were encouraged to think of specific examples from their work, to highlight the particular ethical concerns raised and to describe in detail the process by which those concerns were addressed or left unresolved. All interviews were conducted by the author, face-to-face, in a secluded office between April and May 2013. Interviews lasted from 50 to 70 min, were conducted in English and Urdu, were digitally audio-recorded 264
and transcribed by trained transcriptionists. Urdu transcripts were translated into English by the author. The study was approved by the ethical review committee of the Aga Khan University (2445-EM-ERC-13). Analysis used a constant comparative approach;17 19 that is, the analysis commenced concurrent with the data collection and its transcription. Emerging themes were identified for greater
Box 1 In-depth interview guide An ethical challenge is a situation in the emergency department (ED) where you think moral or ethical values are at stake and are influencing clinical decision making. An ethical dilemma is a situation involving conflict between moral requirements; that is, it is a situation where you might consider taking two different actions with some ethical justification but where taking both actions is not possible and so, you have to make a choice. ▸ Can you list some of the ethical challenges you regularly encounter during your work in the ED? ▸ Can you describe a recent example or a situation that you thought posed an ethical challenge or that you viewed as an ethical dilemma? ▸ What do you consider to be the primary ethical issues raised by this situation? ▸ Please briefly describe the decisions that were made as the situation played itself out, and whether you agreed with those decisions, and why or why not? ▸ Who do you approach for help in solving an ethical challenge or a dilemma? ▸ Can you describe a situation that you were involved in, or that you witnessed, where you thought an ethical challenge or a dilemma was not satisfactorily resolved? What values do you think were at stake? ▸ Have you ever gotten in touch with the hospital’s ethics committee? Can you describe the situation where you needed their help? Were you satisfied with how the situation was dealt with? ▸ Can you describe a situation where you thought you had to offer clinically non-beneficial treatment? How did you feel about it? Do you think advance directives by patients to family or physicians are helpful in these situations? Why or why not. Zafar W. Emerg Med J 2015;32:263–268. doi:10.1136/emermed-2014-204081
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Original article Disclosure and truth-telling
Table 2 Demographic characteristics (n=13) Characteristics Age in years; mean (range) Sex Male Female Status Resident Faculty physician Non-faculty physician Total clinical experience in years; mean (range) Experience in the emergency medicine in years; mean (range) Those who had received any previous training in bioethics
n
% 38.9 (30–53)
9 4
69.2 30.8
5 5 3
38.5 38.5 23.0 13.1 (4–29) 6.8 (3–17)
3
23.0
exploration in subsequent interviews. After analysis of first few interview transcripts, codes were refined and organised into a codebook, which was then systematically applied to the remaining data using ATLAS.ti (V.6.2.26; ATLAS.ti Gmbh, 2011).
RESULTS A total of 13 participants were interviewed (table 2). Mean age of the respondents was 39 years. Nine physicians were men, four were women, five were senior residents (3rd or 4th year) and eight were staff physicians. Respondents had an average of 13 years of total clinical experience and 6.8 years of experience in the ED. Only three respondents reported receiving any formal training in bioethics (a course, workshop, certification programme, etc). Analysis revealed four central themes regarding the common ethical challenges emergency physicians faced (table 3).
Providing highest quality of care with limited resources One recurrent theme brought up by the respondents was the balance between providing best quality care while working with limited resources. Participants repeatedly pointed out the ethically challenging trade-offs they had to make due to limited time per patient. As a result, participants felt unable to provide as much details about planned procedures to the patients as they would have liked, before obtaining their informed consent; to discuss with patients and their families preferences about care; and to provide a sympathetic ear to the family’s grievances that could avoid time-consuming disagreements and conflicts later. Another form of resource constraint was staff shortages. Several residents felt that the ED physicians and nurses were stretched too thin. This meant that, occasionally, junior and less experienced physicians were asked to carry out duties that were normally performed by senior residents and physicians, like obtaining consent for risky procedures or explaining a patient’s poor prognosis to the family. Respondents found this to be ethically challenging because they viewed it as a potentially preventable compromise in care. Other participants pointed to a sense of moral frustration in constantly having to prioritise among competing clinical scenarios. In addition to time and staff shortages, shortages of beds and life-sustaining equipment, including ventilators, were also viewed by participants as forcing them to make trade-offs that had ethical implications. Zafar W. Emerg Med J 2015;32:263–268. doi:10.1136/emermed-2014-204081
The second theme that was repeatedly brought up by ED physicians was the duty to ensure truthful disclosure to patients regarding their diagnosis, treatment options and prognosis while respecting their family’s wishes. The first challenge that participants reported facing in these situations was how to respond to the family’s requests in a sympathetic and consistent manner. One source of ambiguity was that there may be conflict among family members regarding what and how much to disclose and who should do it. Second, participants were more likely to be conflicted when they saw such requests as being rooted in a denial of patient’s condition, a refusal to acknowledge that a patient might already be aware of his or her poor prognosis and a reluctance to engage in an open communication with the patient. Participants were less likely to be conflicted when they viewed such requests as stemming from a desire to shield patients from particularly disheartening or demoralising news. A second challenge that physicians reported facing in such situations was how to ensure an informed consent for various procedures from an otherwise alert and intelligent patient. Participants also worried that disclosing information to patients against the wishes of the family could breach the family’s trust and might even jeopardise patient care, because the family might leave the hospital to seek care elsewhere or may not bring in the patient to ED the next time a medical crisis arose. Conversely, physicians also expressed a concern that by withholding information from a patient, they risked losing her/his trust and could lose face in front of the patient if the patient already knew or found out from another healthcare provider. Nevertheless, it is significant that in describing such situations, all the participants said that they respected the family’s wishes and withheld information that the family had specifically requested them to withhold.
Inability to provide or continue treatment A third theme related to ethical challenges routinely faced by ED physicians dealt with situations where the physicians saw themselves as being unable to care for patients or were forced to ‘ration care in the absence of very clear guidelines’. This emerged as a distinct theme from the first theme highlighted above because it dealt with situations where available resources were completely overwhelmed, and physicians were required to divert patients to other hospitals. Participants brought up these situations as being on a morally different plane than having to provide good quality care under constrained circumstances, which were presented as less satisfying but, nonetheless, less challenging situations. For instance, in describing an ethical challenge, several physicians gave the example of caring for a patient who needs to be intubated and placed on ventilatory support when no ventilators were available in the hospital. In such situations, the patients needed to be shifted, after stabilisation, to other hospitals with available ventilatory support. Some participants saw this as an ethical challenge because of their perception that these situations that resulted in compromised patient care could be avoided if a system existed to coordinate between emergency medical services and the EDs in the city. Other participants saw this as an ethical challenge because they were then forced to do resource allocation with which they were not comfortable. While the study site had a policy of never diverting a patient with a ‘life-threatening’ condition, there were still a number of stable patients in non-‘life-threatening’ situations who needed to be referred to other hospitals because they were unable to pay for 265
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Original article Table 3
Themes, subthemes and illustrative quotes related to common ethical challenges described by the study participants
Main themes
Subthemes
Illustrative quotes
Providing highest quality of care with limited resources
▸ Time shortage ▸ Staff shortage ▸ Inadequate resources
Disclosure and truthtelling
▸ ▸ ▸ ▸
Responding to family's requests Ensuring informed consent by the patient Maintaining trust Avoiding loss of face
Inability to provide or continue treatment
▸ ▸ ▸ ▸
Non-availability of resources Patient's financial inability Possibility of mismanagement in other hospitals When to declare a situation ‘life-threatening’
Providing life-sustaining treatment
▸ Prioritisation and resource allocation ▸ ‘Counselling’ patient's family members regarding the necessity of continued care or responding to requests for treatment of no clinical benefit ▸ Limited relevance of advance directives and hospital ethics committee.
▸ ’(T)he most common challenge is to provide the highest quality care… (which) obviously requires lots of money, and when the patient doesn't have lots of money, how do we tailor the care accordingly, so that the care is not really compromised?’ ▸ ’I think one thing which is very important is time. We are so busy in the ED, in the resuscitation bay, in the step-down unit, that I feel we don't have much time to sit with the family and discuss in detail what they are expecting... So usually we have to discuss it at the bed-side and we have to take decisions within minutes.’ ▸ ‘There are some people who will come to you and who are going to say “The patient knows nothing about his illness. Please don't tell him”. Sometimes it is a conflict because you can see that the patient is smart enough to understand.’ ▸ ‘But being an emergency physician, you have to then listen to the family because that kind of counselling needs more than an emergency session. It needs a lot of things which are not present in an ED. It needs privacy. It needs you to sit down and talk to the family as well as the patient. You don't have time for that when you have 16 or 17 patients waiting for you to talk to them…This is something that the primary physician needs to take care of at his end. So we try to disclose as much as is important.’ ‘We have a patient who has multiple issues. He has surgical problems and has comorbid conditions that require care. The kind of estimates that the patient's family is provided with… are in millions of rupees. Now if they (don't have) that kind of money, we are advised to refer them to another hospital when we think they would be benefited if they are provided care within this hospital. We try to negotiate with the financial counsellors over here. We try to keep the patient within the hospital so that they can meet with the patient welfare office the next morning. In that case, we are taking that responsibility that we are blocking a bed, not referring the patient to another hospital.’ ▸ ‘What do you mean by counselling?’ ‘First, I tell them about what we have found out regarding the disease that the family may not know about; the treatment options that are available to us in this hospital and that may not be available outside and for which they have come to us in the tertiary care; then the pros and cons (of treatment); plus some details about the finances because they have come to a private hospital. So I tell them these are the steps we will take. We also hear the parent's perspective: how much understanding they have regarding the disease, whether they understand about the disease prognosis... We have only 10–15 minutes for counselling. I sit down and explain everything, and then I ask (the parents) what their decision is. I tell them that as a doctor this is my information, but this is your child, and so you make the decision regarding what is best for your child. Sometimes they ask me what I would do if I were in their place so then I say what I think is the best option.’ ▸ ‘The more common scenario is that we think the treatment is necessary and the parents say “Don't do anything.” Let us suppose that a child has been brought in with severe (respiratory) distress and we think she should be intubated. Parents may believe that if a child is put on the breathing machine then she would never come off it, so they will say “Treat her but don't intubate.” But if we don't intubate, the patient will collapse. Then it is a more difficult situation compared with when parents are asking us to do everything possible. That (latter) is an easy situation where you have intubated the patient and done everything and then you can sit down and patiently explain to them that there is no prognosis or benefit, and then you can withdraw treatment on your own timeline. The more difficult situation is when you think it (the medical crisis) is reversible... In such situations we try very hard to explain to the parents.’ ▸ ‘They (the hospital ethics committee) are actually not very useful to us. They don't have a sense of the issues we deal with. They think they will get involved in complex ethical issues, and they think in the ED there are no complex ethical issues. Their capacity to help us out is very limited. Our trust in the speed with which they will respond is also limited. The agreement on what an ethical issue is, is not there.’
ED, emergency department.
their care. The participants especially portrayed this as an ethical dilemma in those situations where the patient had multiple complicated problems, was clearly unable to pay for care and was unlikely to receive good quality care in other hospitals. In such cases, ED physicians were faced with the morally troubling question of when to label a situation as ‘life-threatening’ that could 266
determine whether a patient received care or not. Faced with having to balance their fiduciary responsibility to the hospital as its employees and their responsibility to the patients, ED physicians were forced to exercise carefully calibrated clinical decisions and to engage in negotiations with the patient’s family and the financial counsellors from the patient welfare office of the hospital. Zafar W. Emerg Med J 2015;32:263–268. doi:10.1136/emermed-2014-204081
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Original article Providing life-sustaining treatments A final set of ethical challenges repeatedly brought up by the participants related to providing life-sustaining treatments especially when patients were very sick or at the end of life. Even with acutely sick patients, where clinical decision making was portrayed as morally least ambiguous because of the overriding imperative to save a patient’s life, ED physicians reported facing dilemmas regarding intubating someone without ensuring availability of a ventilator beforehand or placing someone with a very poor prognosis on life-sustaining treatments. Putting someone on a ventilator was a decision ED physicians in this study faced daily—three to four patients in every 12 h, according to one physician’s estimate. One area of participants’ concern within this theme was the need for patient prioritisation and resource allocation. Patients in this ED were triaged based on an established protocol into five mutually exclusive levels (level 1 was the highest risk and level 5 the lowest) by a triage nurse. According to participants’ accounts, priority for receiving life-sustaining treatments was established by the patient’s triage level, on a first-come, first-served basis. In situations where there were more patients of equal priority than the number of available ventilators, those clinically seen as most likely to benefit from treatment were accorded precedence over patients seen as ‘unsalvageable.’ Despite the existence of this triage framework, most ED physicians still viewed the issues of resource allocation as ethically ‘some of the most challenging problems’. A second ethically challenging aspect of providing care to patients in life-threatening situations was the necessity of discussing with the family the disease prognosis and treatment options and to elicit patient’s and family’s preferences regarding care. Participants frequently referred to this communication as ‘counselling’. On some occasions, at least, counselling could be a form of more directed communication between the physician and the family members. This happened in two situations in particular: more commonly, when family members were requesting the participants to not initiate or stop the treatment of a patient whose condition was seen as reversible by the healthcare team and less commonly, when the family was requesting treatment of no clinical benefit. Dealing with latter requests was seen as ethically challenging because, on the one hand, there was a strong imperative to employ resources efficiently within the ED. On the other hand, such requests by emotionally agitated family members in situations of incomplete information and clinical uncertainty could be difficult to respond to, particularly by more junior ED physicians. None of the participants interviewed for this study thought that advance directives—written or explicitly expressed wishes of the patient regarding end-of-life care—helped them in resolving ethical challenges about life-sustaining treatments. Physicians cited several reasons for the limited relevance of advance directives or ‘do-not-resuscitate’ (DNR) code status in the ED practice. First, most patients seen in this ED, even those with terminal illnesses, did not have advance directives and, apparently, had never had any discussions about their end-of-life care preferences with their families or treating physicians. Second, ED physicians might not consider the advance directives to be applicable to potentially reversible situations. Third, the respondents thought that since advance directives and DNR code status were not legally binding in Pakistan, therefore they respected the wishes of close family members of the patient in making end-of-life care decisions. Finally, it is noteworthy that even though ethical challenges were reported to be relatively commonplace in the ED practice, Zafar W. Emerg Med J 2015;32:263–268. doi:10.1136/emermed-2014-204081
study participants did not point to any particular mechanism of systematically resolving them. Most participants suggested that they relied on the ED’s established protocols, guidance from senior ED physicians, consensus of the healthcare team, and their own clinical training and moral intuition in resolving these challenges. In this regard, the hospital’s ethics committee (HEC) was seen to be of limited help. Regarding the common ethical challenges faced by ED physicians, HEC was viewed as practically unavailable outside of normal business hours, slow in responding to emergent situations, unable to provide answers in light of the often limited information on which ED physicians need to base their decisions and holding a conception of bioethics and ethical challenges that was largely academic and somewhat divorced from reality.
DISCUSSION ED physicians’ narratives provided important insights into how physicians of varying clinical experience and training tried to resolve ethical challenges in the ‘local moral world’ of an ED in Pakistan. One significant finding of this study is that ED physicians did frequently face challenges in their everyday practice where they thought ethical values were at stake and where moral, in addition to clinical, decision making was needed. While some of these challenges have been previously described in the literature, more work is needed to truly contextualise them and, hence, develop a more nuanced understanding about them. For instance, most physicians in this study described withholding information from patients as an ethical challenge. Previous work has suggested that withholding information from patients is an example of how ‘understandings of morality and health care’ might differ across cultures (ref. 20, p.109; refs. 21 and 22). However, this study finds that Pakistani ED physicians did not necessarily find withholding information from patients on their families’ request any less morally troubling than their Western counterparts. The difference seems to arise not so much from an alternative moral worldview as from the priority afforded to the views of various stakeholders. That none of the study participants suggested they would disclose any information to a patient that the patient’s family had explicitly asked them to withhold, was framed by the respondents as an indicator of the pragmatic approach that they adopt in order to assure patients’ continued and efficient care in the ED rather than a deeply held, widely shared, and culturally relative moral stance. It is also noteworthy that in this context participants were likely to frame their moral reasoning within a pragmatic framework by emphasising the local context and their efforts to achieve best results in the given circumstances rather than within alternative (utilitarian, principlist or deontological) frameworks. This study also found that in resolving common ethical challenges, ED physicians found HEC to be of limited help. While HECs and ethics consults have been found to be effective in reducing life-sustaining treatments of no clinical benefit in the intensive care settings,23 their role in the ED settings remains underexplored. More work is needed to understand how the deliberate way in which many HECs operate can be adapted to the frenetic pace of the ED to help resolve common ethical challenges. Physicians working in an ED in a large metropolis of a low income country unsurprisingly brought up issues around providing patient care in the face of significant resource constraints as morally challenging. However, other expected ethical challenges were mentioned only infrequently. These included how to remain professional in dealing with violent behaviour of patients and their families,24 what to do in cases where child abuse or 267
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Original article domestic violence is suspected and how to handle unprofessional conduct by colleagues. Finally, this study highlights the need for structured ethics training during EM residency to help the residents deal with common ethical challenges in the ED, especially since only three out of 13 participants reported receiving any training in bioethics. Future work should focus on developing a contextually appropriate curriculum for ethics trainings of EM residents and on identifying the most effective methods for teaching and evaluating these competencies. This study has several limitations. First, the study relied on a relatively small number of in-depth interviews of physicians working in a private sector ED. However, there are only two accredited EM residency training programmes in Pakistan, both in the private sector. In this context, the perspectives of physicians in one of the first programmes in the country are illustrative of problems likely to be faced elsewhere. Future work would add to this study’s findings by focusing on the perspectives of ED physicians working in public hospitals, ED patients and their families, nurses, medical students, ED managers, and through participant observations. Second, the author did the interviews, their thematic analyses and, where needed, their translation into English. The problems associated with this design were minimised by member checking the themes highlighted in earlier interviews with subsequent participants. Not having an ED clinician as a coinvestigator both allowed a larger pool of eligible participants and likely encouraged the respondents to express their views more freely. Translations were much less of a problem because English is the primary language of medical education and clinical work in Pakistan. Respondents, therefore, even when speaking in Urdu, mostly used categories and concepts that were easily translatable into English. Nevertheless, the study also has several important strengths. It is one of the few studies from low-income and middle-income countries that have looked at providers’ perspectives on the ethical challenges faced by ED physicians. While a few studies have used healthcare providers’ narratives to understand common ethical challenges faced in clinical practice, these studies have not focused on emergency physicians.25 This study also demonstrates the use of focusing on providers’ narratives to contextualise and add nuance to the literature on clinical ethics. Everyday work in the ‘local moral world’ of an ED poses frequent ethical challenges for physicians. While these challenges probably vary depending on the cultural, economic and clinical context, the necessity to deal with them consistently and effectively remains essential for good clinical practice. Work on identifying these challenges and how best to respond to them is still nascent. This study takes a step in that direction by presenting the perspectives of ED physicians practicing in Pakistan regarding what they find ethically challenging in their clinical experiences. Acknowledgements The author acknowledges helpful feedback from Dr Junaid A Razzak and Dr Uzma R Khan on an earlier version of this research. He is also grateful to Shumaila Rupani and Nishi Shakil for help with transcription; to the physicians and residents in the Department of Emergency Medicine, Aga Khan University, Karachi, for their participation in this study; and to the two anonymous reviewers for their helpful feedback. The content is solely the responsibility of the author and does not represent the official views or policies of the Department of Emergency Medicine or the Aga Khan University.
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Contributors WZ designed the study, obtained approvals, conducted interviews, translated transcripts, did the analyses, wrote the manuscript, approved the final version and takes responsibility for the paper as a whole. Competing interests None. Ethics approval The ethical review committee of the Aga Khan University. Provenance and peer review Not commissioned; externally peer reviewed.
REFERENCES 1 2
3
4 5 6 7 8 9 10 11 12 13 14 15 16 17
18 19 20 21 22
23
24
25
Moskop JC. Informed consent in the emergency department. Emerg Med Clin North Am 1999;17:327–40. Larkin GL, Marco CA, Abbott JT. Emergency determination of decision-making capacity: Balancing autonomy and beneficence in the emergency department. Acad Emerg Med 2001;8:282–4. Moskop JC, Marco CA, Larkin GL, et al. From Hippocrates to HIPAA: privacy and confidentiality in emergency medicine-part II: Challenges in the emergency department. Ann Emerg Med 2005;45:60–7. Jecker NS, Schneiderman LJ. When families request that ‘everything possible’ be done. J Med Philos 1995;20:145–63. Marco CA, Larkin GL, Moskop JC, et al. Determination of “futility” in emergency medicine. Ann Emerg Med 2000;35:604–12. Quill TE. Initiating end-of-life discussions with seriously ill patients: addressing the “elephant in the room”. JAMA 2000;284:2502–7. Fins J, Miller FG, Bacchetta MD. Clinical pragmatism: a method of moral problem solving. Kennedy Inst Ethics J 1997;7:129–43. Kaldjian LC, Weir RF, Duffy TP. A clinician’s approach to clinical ethical reasoning. J Gen Inter Med 2005;20:306–11. Rhodes R, Alfandre D. A systematic approach to clinical moral reasoning. Clin Ethics 2007;2:66–70. Santen SA, Hemphill RR. A window on professionalism in the emergency department through medical student narratives. Ann Emerg Med 2011;58:288–94. Arnold JL. International emergency medicine and the recent development of emergency medicine worldwide. Ann Emerg Med 1999;33:97–103. Arnold JL, Dickinson G, Tsai MC, et al. A survey of emergency medicine in 36 countries. CJEM 2001;3:109–18. Corley MC, Elswick RK, Gorman M, et al. Development and evaluation of a moral distress scale. J Adv Nurs 2001;33:250–6. Kalvemark S, Hoglund AT, Hansson MG, et al. Living with conflicts-ethical dilemma and moral distress in the health care system. Soc Sci Med 2004;58:1075–84. Yang LH, Kleinman A, Link BG, et al. Culture and stigma: adding moral experience to stigma theory. Soc Sci Med 2007;64:1524–35. Kleinman A. Moral experience and ethical reflection: Can ethnography reconcile them? A quandary for “the new bioethics”. Daedalus 1999;128:69–97. Corbin J, Strauss A. Basics of qualitative research: techniques and procedures for developing grounded theory. 3rd edn. Thousand Oaks: SAGE Publications, Inc, 2007. Guest G, Bunce A, Johnson L. How many interviews are enough? An experiment with data saturation and variability. Field Methods 2006;18:59. Beoije H. A purposeful approach to the constant comparative method in the analysis of qualitative interviews. Qual Quant 2002;36:391–409. Turner L. Bioethics in a multicultural world: Medicine and morality in pluralistic settings. Health Care Anal 2003;11:99–117. Orona C, Koenig B, Davis A. Cultural aspects of nondisclosure. Camb Q Healthc Ethics 1994;3:338–46. Lapine A, Wang-Cheng R, Goldstein M, et al. When cultures clash: physician, patient, and family wishes in truth disclosure for dying patients. J Palliat Med 2001;4:475–80. Schneidermann LJ, Gilmer T, Teetzel HD, et al. Effect of ethics consultations on nonbeneficial life-sustaining treatments in the intensive care setting. JAMA 2003;290:1166–72. Zafar W, Siddiqui E, Ejaz K, et al. Health care personnel and workplace violence in the emergency departments of a volatile metropolis: Results from Karachi, Pakistan. J Emerg Med 2013;45:761–72. Sorlie V, Forde R, Lindseth A, et al. Male physicians’ narratives about being in ethically difficult care situations in paediatrics. Soc Sci Med 2001;53:657–67.
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Moral experience and ethical challenges in an emergency department in Pakistan: emergency physicians' perspectives Waleed Zafar Emerg Med J 2015 32: 263-268 originally published online September 18, 2014
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Original article
Moral experience and ethical challenges in an emergency department in Pakistan: emergency physicians’ perspectives Waleed Zafar ▸ Additional material is published online only. To view please visit the journal online (http://dx.doi.org/10.1136/ emermed-2014-204081). Correspondence to Dr Waleed Zafar, Department of Emergency Medicine, Aga Khan University, Stadium Road, P.O. Box 3500, Karachi 74800, Pakistan; [email protected] Received 6 June 2014 Revised 1 August 2014 Accepted 15 August 2014 Published Online First 18 September 2014
ABSTRACT Introduction Emergency departments (ED) are often stressful environments posing unique ethical challenges —issues that primarily raise moral rather than clinical concerns—in patient care. Despite this, there are very few reports of what emergency physicians find ethically challenging in their everyday work. Emergency medicine (EM) is a relatively young but rapidly growing specialty that is gaining acceptance worldwide. The aim of this study was to explore the perspectives of EM residents and physicians regarding the common ethical challenges they face during patient care in one of only two academic EM departments in Pakistan. These challenges could then be addressed in residents’ training and departmental practice guidelines. Methods A qualitative research design was employed and in-depth interviews were conducted with ED physicians. Participants were encouraged to think of specific examples from their work, to highlight the particular ethical concerns raised and to describe in detail the process by which those concerns were addressed or left unresolved. Transcripts were analysed using grounded theory methods. Results Thirteen participants were interviewed and they described four key challenges: how to provide highest quality care with limited resources; how to be truthful to patients; what to do when it is not possible to provide or continue treatment to patients; and when (and when not) to offer life-sustaining treatments. Participants’ accounts provided important insights into how physicians tried to resolve these challenges in the ‘local moral world’ of an ED in Pakistan. Conclusions The study highlights the need for developing systematic and contextually appropriate mechanisms for resolving common ethical challenges in the EDs and for training residents in moral problem solving.
INTRODUCTION
▸ http://dx.doi.org/10.1136/ emermed-2014-204252
To cite: Zafar W. Emerg Med J 2015;32:263–268.
Emergency departments (ED) are often stressful environments where emergency physicians and nurses manage acutely ill patients under resourceconstrained and time-constrained circumstances. Work under such circumstances can pose unique ethical challenges in patient care—issues that primarily raise moral rather than clinical concerns. These challenges include management of patients who may or may not be in a position to give informed consent,1 2 the need to maintain patient privacy and confidentiality in a disordered space,3 dealing with requests to provide treatment of no clinical benefit4 5 and discussing sensitive and difficult decisions regarding end of life with patients and families.6 Moreover, the time needed for
Key messages What is already known on this subject? ED physicians in an ED in Pakistan reported facing frequent ethical challenges in their everyday practice which require moral, in addition to clinical, decision-making. Available resources were viewed to be of limited help, and little formal training was given on how to handle these issues. What might this study add? There is a need for developing systematic and contextually-appropriate mechanisms for resolving common ethical challenges in low-resource EDs and for training residents in moral problemsolving.
dispassionate analysis of facts and application of moral reasoning suggested for clinicians may not be available to ED physicians.7–9 Despite this, there are very few reports of what emergency physicians find ethically challenging in their everyday work.10 Emergency medicine (EM) is a relatively young but rapidly growing specialty that is gaining acceptance worldwide.11 12 It is, therefore, especially important to understand what moral challenges emergency physicians face and to think about how best to resolve them. Unresolved moral challenges can lead to moral distress—painful feelings that occur when the healthcare provider does not know what the morally right thing to do is or, because of institutional constraints, is unable to act according to his or her moral judgment—and is associated with low job satisfaction, staff turnover, physician burnout and poor patient care.13 14 The aim of this study was to explore the perspectives of EM residents and physicians in one of only two academic EM departments in Pakistan regarding the common ethical challenges they faced during patient care. In exploring the physicians’ perspectives, the study primarily drew on Arthur Kleinman’s theory of ‘moral experience, or what is at stake for actors in a local moral world’ (ref. 15, p.1525). In conceptualising ED as a ‘local moral world’, this study focused on physicians’ ‘lived’ experiences trying to balance the moral demands of their profession and the variety of constraints under which they operate.16 Consequently, the aim was neither to evaluate physicians’ understanding of bioethical principles, vocabulary or discourse, nor to illustrate ethical challenges in EM that may be universally relevant. Instead, the goal was to understand, in physicians’ own words, the situations
Zafar W. Emerg Med J 2015;32:263–268. doi:10.1136/emermed-2014-204081
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Original article Table 1 A comparison of the study site with some of the other large hospitals in Karachi, Pakistan
Hospital
Sector
Aga Khan University*
Private non-profit
Liaquat National
Private non-profit
Civil Karachi
Public
Jinnah Postgraduate Medical Centre
Public
Abbasi Shaheed
Public
Approximate number of providers in ED per day (all shifts included)
Approximate number of patients seen per day in the ED
Approximate total number of beds in the hospital
35–45 physicians; 45–55 nurses 20–25 physicians; 45–50 nurses 15–25 physicians; 20–30 nurses 25–30 physicians; 20–35 nurses 25–35 physicians; 50–60 nurses
200–250
600
Yes
180–220
700
No
900–1200
1900
No
900–1200
1300
No
900–1200
850
No
Provides graduate training in EM
*Study site. ED, emergency department; EM, emergency medicine.
or circumstances that they find ethically challenging in their local cultural, economic and clinical context.
METHODS Setting and context Semistructured in-depth interviews were conducted with EM residents and physicians working in an academic EM department and ED in a teaching hospital in Karachi, Pakistan. This site, a private non-profit hospital that serves about 200–250 patients per day in its ED, was selected because it is one of only two programmes to offer EM residency training in Pakistan. The residency programme follows an indigenously developed EM curriculum that is approved by the College of Physicians and Surgeons of Pakistan, and is closely based on the guidelines by the US Accreditation Council for Graduate Medical Education. A comparison of the study site with some of the other large hospitals in Karachi is presented in table 1. For a brief note on the health system in Pakistan and the emergency care landscape in Karachi, please see the online supplement. The aim of the study was to understand common ethical challenges faced in the ED that can then be addressed in residents’ training and departmental practice guidelines.
Data collection and analysis An interview guide (box 1) was developed to understand in detail emergency physicians’ perspectives on the common ethical challenges they faced during clinical work. Initial version of the guide was tested with three residents. Physicians working full-time in the ED and senior (3rd and 4th year) residents in the EM residency programme were considered for inclusion in this study. Purposive sampling was used to assure adequate representation of perspectives from various training tracks and in terms of gender and years of clinical experience.17 Enrolment was continued until saturation of key themes.17 18 The interviewer, a full-time physician-researcher with no training in EM, began by reading to the participants a generic definition of ‘ethical challenge’ and ‘ethical dilemma’ and then asked nine open-ended questions about common ethical challenges faced in the ED. Participants were encouraged to think of specific examples from their work, to highlight the particular ethical concerns raised and to describe in detail the process by which those concerns were addressed or left unresolved. All interviews were conducted by the author, face-to-face, in a secluded office between April and May 2013. Interviews lasted from 50 to 70 min, were conducted in English and Urdu, were digitally audio-recorded 264
and transcribed by trained transcriptionists. Urdu transcripts were translated into English by the author. The study was approved by the ethical review committee of the Aga Khan University (2445-EM-ERC-13). Analysis used a constant comparative approach;17 19 that is, the analysis commenced concurrent with the data collection and its transcription. Emerging themes were identified for greater
Box 1 In-depth interview guide An ethical challenge is a situation in the emergency department (ED) where you think moral or ethical values are at stake and are influencing clinical decision making. An ethical dilemma is a situation involving conflict between moral requirements; that is, it is a situation where you might consider taking two different actions with some ethical justification but where taking both actions is not possible and so, you have to make a choice. ▸ Can you list some of the ethical challenges you regularly encounter during your work in the ED? ▸ Can you describe a recent example or a situation that you thought posed an ethical challenge or that you viewed as an ethical dilemma? ▸ What do you consider to be the primary ethical issues raised by this situation? ▸ Please briefly describe the decisions that were made as the situation played itself out, and whether you agreed with those decisions, and why or why not? ▸ Who do you approach for help in solving an ethical challenge or a dilemma? ▸ Can you describe a situation that you were involved in, or that you witnessed, where you thought an ethical challenge or a dilemma was not satisfactorily resolved? What values do you think were at stake? ▸ Have you ever gotten in touch with the hospital’s ethics committee? Can you describe the situation where you needed their help? Were you satisfied with how the situation was dealt with? ▸ Can you describe a situation where you thought you had to offer clinically non-beneficial treatment? How did you feel about it? Do you think advance directives by patients to family or physicians are helpful in these situations? Why or why not. Zafar W. Emerg Med J 2015;32:263–268. doi:10.1136/emermed-2014-204081
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Original article Disclosure and truth-telling
Table 2 Demographic characteristics (n=13) Characteristics Age in years; mean (range) Sex Male Female Status Resident Faculty physician Non-faculty physician Total clinical experience in years; mean (range) Experience in the emergency medicine in years; mean (range) Those who had received any previous training in bioethics
n
% 38.9 (30–53)
9 4
69.2 30.8
5 5 3
38.5 38.5 23.0 13.1 (4–29) 6.8 (3–17)
3
23.0
exploration in subsequent interviews. After analysis of first few interview transcripts, codes were refined and organised into a codebook, which was then systematically applied to the remaining data using ATLAS.ti (V.6.2.26; ATLAS.ti Gmbh, 2011).
RESULTS A total of 13 participants were interviewed (table 2). Mean age of the respondents was 39 years. Nine physicians were men, four were women, five were senior residents (3rd or 4th year) and eight were staff physicians. Respondents had an average of 13 years of total clinical experience and 6.8 years of experience in the ED. Only three respondents reported receiving any formal training in bioethics (a course, workshop, certification programme, etc). Analysis revealed four central themes regarding the common ethical challenges emergency physicians faced (table 3).
Providing highest quality of care with limited resources One recurrent theme brought up by the respondents was the balance between providing best quality care while working with limited resources. Participants repeatedly pointed out the ethically challenging trade-offs they had to make due to limited time per patient. As a result, participants felt unable to provide as much details about planned procedures to the patients as they would have liked, before obtaining their informed consent; to discuss with patients and their families preferences about care; and to provide a sympathetic ear to the family’s grievances that could avoid time-consuming disagreements and conflicts later. Another form of resource constraint was staff shortages. Several residents felt that the ED physicians and nurses were stretched too thin. This meant that, occasionally, junior and less experienced physicians were asked to carry out duties that were normally performed by senior residents and physicians, like obtaining consent for risky procedures or explaining a patient’s poor prognosis to the family. Respondents found this to be ethically challenging because they viewed it as a potentially preventable compromise in care. Other participants pointed to a sense of moral frustration in constantly having to prioritise among competing clinical scenarios. In addition to time and staff shortages, shortages of beds and life-sustaining equipment, including ventilators, were also viewed by participants as forcing them to make trade-offs that had ethical implications. Zafar W. Emerg Med J 2015;32:263–268. doi:10.1136/emermed-2014-204081
The second theme that was repeatedly brought up by ED physicians was the duty to ensure truthful disclosure to patients regarding their diagnosis, treatment options and prognosis while respecting their family’s wishes. The first challenge that participants reported facing in these situations was how to respond to the family’s requests in a sympathetic and consistent manner. One source of ambiguity was that there may be conflict among family members regarding what and how much to disclose and who should do it. Second, participants were more likely to be conflicted when they saw such requests as being rooted in a denial of patient’s condition, a refusal to acknowledge that a patient might already be aware of his or her poor prognosis and a reluctance to engage in an open communication with the patient. Participants were less likely to be conflicted when they viewed such requests as stemming from a desire to shield patients from particularly disheartening or demoralising news. A second challenge that physicians reported facing in such situations was how to ensure an informed consent for various procedures from an otherwise alert and intelligent patient. Participants also worried that disclosing information to patients against the wishes of the family could breach the family’s trust and might even jeopardise patient care, because the family might leave the hospital to seek care elsewhere or may not bring in the patient to ED the next time a medical crisis arose. Conversely, physicians also expressed a concern that by withholding information from a patient, they risked losing her/his trust and could lose face in front of the patient if the patient already knew or found out from another healthcare provider. Nevertheless, it is significant that in describing such situations, all the participants said that they respected the family’s wishes and withheld information that the family had specifically requested them to withhold.
Inability to provide or continue treatment A third theme related to ethical challenges routinely faced by ED physicians dealt with situations where the physicians saw themselves as being unable to care for patients or were forced to ‘ration care in the absence of very clear guidelines’. This emerged as a distinct theme from the first theme highlighted above because it dealt with situations where available resources were completely overwhelmed, and physicians were required to divert patients to other hospitals. Participants brought up these situations as being on a morally different plane than having to provide good quality care under constrained circumstances, which were presented as less satisfying but, nonetheless, less challenging situations. For instance, in describing an ethical challenge, several physicians gave the example of caring for a patient who needs to be intubated and placed on ventilatory support when no ventilators were available in the hospital. In such situations, the patients needed to be shifted, after stabilisation, to other hospitals with available ventilatory support. Some participants saw this as an ethical challenge because of their perception that these situations that resulted in compromised patient care could be avoided if a system existed to coordinate between emergency medical services and the EDs in the city. Other participants saw this as an ethical challenge because they were then forced to do resource allocation with which they were not comfortable. While the study site had a policy of never diverting a patient with a ‘life-threatening’ condition, there were still a number of stable patients in non-‘life-threatening’ situations who needed to be referred to other hospitals because they were unable to pay for 265
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Original article Table 3
Themes, subthemes and illustrative quotes related to common ethical challenges described by the study participants
Main themes
Subthemes
Illustrative quotes
Providing highest quality of care with limited resources
▸ Time shortage ▸ Staff shortage ▸ Inadequate resources
Disclosure and truthtelling
▸ ▸ ▸ ▸
Responding to family's requests Ensuring informed consent by the patient Maintaining trust Avoiding loss of face
Inability to provide or continue treatment
▸ ▸ ▸ ▸
Non-availability of resources Patient's financial inability Possibility of mismanagement in other hospitals When to declare a situation ‘life-threatening’
Providing life-sustaining treatment
▸ Prioritisation and resource allocation ▸ ‘Counselling’ patient's family members regarding the necessity of continued care or responding to requests for treatment of no clinical benefit ▸ Limited relevance of advance directives and hospital ethics committee.
▸ ’(T)he most common challenge is to provide the highest quality care… (which) obviously requires lots of money, and when the patient doesn't have lots of money, how do we tailor the care accordingly, so that the care is not really compromised?’ ▸ ’I think one thing which is very important is time. We are so busy in the ED, in the resuscitation bay, in the step-down unit, that I feel we don't have much time to sit with the family and discuss in detail what they are expecting... So usually we have to discuss it at the bed-side and we have to take decisions within minutes.’ ▸ ‘There are some people who will come to you and who are going to say “The patient knows nothing about his illness. Please don't tell him”. Sometimes it is a conflict because you can see that the patient is smart enough to understand.’ ▸ ‘But being an emergency physician, you have to then listen to the family because that kind of counselling needs more than an emergency session. It needs a lot of things which are not present in an ED. It needs privacy. It needs you to sit down and talk to the family as well as the patient. You don't have time for that when you have 16 or 17 patients waiting for you to talk to them…This is something that the primary physician needs to take care of at his end. So we try to disclose as much as is important.’ ‘We have a patient who has multiple issues. He has surgical problems and has comorbid conditions that require care. The kind of estimates that the patient's family is provided with… are in millions of rupees. Now if they (don't have) that kind of money, we are advised to refer them to another hospital when we think they would be benefited if they are provided care within this hospital. We try to negotiate with the financial counsellors over here. We try to keep the patient within the hospital so that they can meet with the patient welfare office the next morning. In that case, we are taking that responsibility that we are blocking a bed, not referring the patient to another hospital.’ ▸ ‘What do you mean by counselling?’ ‘First, I tell them about what we have found out regarding the disease that the family may not know about; the treatment options that are available to us in this hospital and that may not be available outside and for which they have come to us in the tertiary care; then the pros and cons (of treatment); plus some details about the finances because they have come to a private hospital. So I tell them these are the steps we will take. We also hear the parent's perspective: how much understanding they have regarding the disease, whether they understand about the disease prognosis... We have only 10–15 minutes for counselling. I sit down and explain everything, and then I ask (the parents) what their decision is. I tell them that as a doctor this is my information, but this is your child, and so you make the decision regarding what is best for your child. Sometimes they ask me what I would do if I were in their place so then I say what I think is the best option.’ ▸ ‘The more common scenario is that we think the treatment is necessary and the parents say “Don't do anything.” Let us suppose that a child has been brought in with severe (respiratory) distress and we think she should be intubated. Parents may believe that if a child is put on the breathing machine then she would never come off it, so they will say “Treat her but don't intubate.” But if we don't intubate, the patient will collapse. Then it is a more difficult situation compared with when parents are asking us to do everything possible. That (latter) is an easy situation where you have intubated the patient and done everything and then you can sit down and patiently explain to them that there is no prognosis or benefit, and then you can withdraw treatment on your own timeline. The more difficult situation is when you think it (the medical crisis) is reversible... In such situations we try very hard to explain to the parents.’ ▸ ‘They (the hospital ethics committee) are actually not very useful to us. They don't have a sense of the issues we deal with. They think they will get involved in complex ethical issues, and they think in the ED there are no complex ethical issues. Their capacity to help us out is very limited. Our trust in the speed with which they will respond is also limited. The agreement on what an ethical issue is, is not there.’
ED, emergency department.
their care. The participants especially portrayed this as an ethical dilemma in those situations where the patient had multiple complicated problems, was clearly unable to pay for care and was unlikely to receive good quality care in other hospitals. In such cases, ED physicians were faced with the morally troubling question of when to label a situation as ‘life-threatening’ that could 266
determine whether a patient received care or not. Faced with having to balance their fiduciary responsibility to the hospital as its employees and their responsibility to the patients, ED physicians were forced to exercise carefully calibrated clinical decisions and to engage in negotiations with the patient’s family and the financial counsellors from the patient welfare office of the hospital. Zafar W. Emerg Med J 2015;32:263–268. doi:10.1136/emermed-2014-204081
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Original article Providing life-sustaining treatments A final set of ethical challenges repeatedly brought up by the participants related to providing life-sustaining treatments especially when patients were very sick or at the end of life. Even with acutely sick patients, where clinical decision making was portrayed as morally least ambiguous because of the overriding imperative to save a patient’s life, ED physicians reported facing dilemmas regarding intubating someone without ensuring availability of a ventilator beforehand or placing someone with a very poor prognosis on life-sustaining treatments. Putting someone on a ventilator was a decision ED physicians in this study faced daily—three to four patients in every 12 h, according to one physician’s estimate. One area of participants’ concern within this theme was the need for patient prioritisation and resource allocation. Patients in this ED were triaged based on an established protocol into five mutually exclusive levels (level 1 was the highest risk and level 5 the lowest) by a triage nurse. According to participants’ accounts, priority for receiving life-sustaining treatments was established by the patient’s triage level, on a first-come, first-served basis. In situations where there were more patients of equal priority than the number of available ventilators, those clinically seen as most likely to benefit from treatment were accorded precedence over patients seen as ‘unsalvageable.’ Despite the existence of this triage framework, most ED physicians still viewed the issues of resource allocation as ethically ‘some of the most challenging problems’. A second ethically challenging aspect of providing care to patients in life-threatening situations was the necessity of discussing with the family the disease prognosis and treatment options and to elicit patient’s and family’s preferences regarding care. Participants frequently referred to this communication as ‘counselling’. On some occasions, at least, counselling could be a form of more directed communication between the physician and the family members. This happened in two situations in particular: more commonly, when family members were requesting the participants to not initiate or stop the treatment of a patient whose condition was seen as reversible by the healthcare team and less commonly, when the family was requesting treatment of no clinical benefit. Dealing with latter requests was seen as ethically challenging because, on the one hand, there was a strong imperative to employ resources efficiently within the ED. On the other hand, such requests by emotionally agitated family members in situations of incomplete information and clinical uncertainty could be difficult to respond to, particularly by more junior ED physicians. None of the participants interviewed for this study thought that advance directives—written or explicitly expressed wishes of the patient regarding end-of-life care—helped them in resolving ethical challenges about life-sustaining treatments. Physicians cited several reasons for the limited relevance of advance directives or ‘do-not-resuscitate’ (DNR) code status in the ED practice. First, most patients seen in this ED, even those with terminal illnesses, did not have advance directives and, apparently, had never had any discussions about their end-of-life care preferences with their families or treating physicians. Second, ED physicians might not consider the advance directives to be applicable to potentially reversible situations. Third, the respondents thought that since advance directives and DNR code status were not legally binding in Pakistan, therefore they respected the wishes of close family members of the patient in making end-of-life care decisions. Finally, it is noteworthy that even though ethical challenges were reported to be relatively commonplace in the ED practice, Zafar W. Emerg Med J 2015;32:263–268. doi:10.1136/emermed-2014-204081
study participants did not point to any particular mechanism of systematically resolving them. Most participants suggested that they relied on the ED’s established protocols, guidance from senior ED physicians, consensus of the healthcare team, and their own clinical training and moral intuition in resolving these challenges. In this regard, the hospital’s ethics committee (HEC) was seen to be of limited help. Regarding the common ethical challenges faced by ED physicians, HEC was viewed as practically unavailable outside of normal business hours, slow in responding to emergent situations, unable to provide answers in light of the often limited information on which ED physicians need to base their decisions and holding a conception of bioethics and ethical challenges that was largely academic and somewhat divorced from reality.
DISCUSSION ED physicians’ narratives provided important insights into how physicians of varying clinical experience and training tried to resolve ethical challenges in the ‘local moral world’ of an ED in Pakistan. One significant finding of this study is that ED physicians did frequently face challenges in their everyday practice where they thought ethical values were at stake and where moral, in addition to clinical, decision making was needed. While some of these challenges have been previously described in the literature, more work is needed to truly contextualise them and, hence, develop a more nuanced understanding about them. For instance, most physicians in this study described withholding information from patients as an ethical challenge. Previous work has suggested that withholding information from patients is an example of how ‘understandings of morality and health care’ might differ across cultures (ref. 20, p.109; refs. 21 and 22). However, this study finds that Pakistani ED physicians did not necessarily find withholding information from patients on their families’ request any less morally troubling than their Western counterparts. The difference seems to arise not so much from an alternative moral worldview as from the priority afforded to the views of various stakeholders. That none of the study participants suggested they would disclose any information to a patient that the patient’s family had explicitly asked them to withhold, was framed by the respondents as an indicator of the pragmatic approach that they adopt in order to assure patients’ continued and efficient care in the ED rather than a deeply held, widely shared, and culturally relative moral stance. It is also noteworthy that in this context participants were likely to frame their moral reasoning within a pragmatic framework by emphasising the local context and their efforts to achieve best results in the given circumstances rather than within alternative (utilitarian, principlist or deontological) frameworks. This study also found that in resolving common ethical challenges, ED physicians found HEC to be of limited help. While HECs and ethics consults have been found to be effective in reducing life-sustaining treatments of no clinical benefit in the intensive care settings,23 their role in the ED settings remains underexplored. More work is needed to understand how the deliberate way in which many HECs operate can be adapted to the frenetic pace of the ED to help resolve common ethical challenges. Physicians working in an ED in a large metropolis of a low income country unsurprisingly brought up issues around providing patient care in the face of significant resource constraints as morally challenging. However, other expected ethical challenges were mentioned only infrequently. These included how to remain professional in dealing with violent behaviour of patients and their families,24 what to do in cases where child abuse or 267
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Original article domestic violence is suspected and how to handle unprofessional conduct by colleagues. Finally, this study highlights the need for structured ethics training during EM residency to help the residents deal with common ethical challenges in the ED, especially since only three out of 13 participants reported receiving any training in bioethics. Future work should focus on developing a contextually appropriate curriculum for ethics trainings of EM residents and on identifying the most effective methods for teaching and evaluating these competencies. This study has several limitations. First, the study relied on a relatively small number of in-depth interviews of physicians working in a private sector ED. However, there are only two accredited EM residency training programmes in Pakistan, both in the private sector. In this context, the perspectives of physicians in one of the first programmes in the country are illustrative of problems likely to be faced elsewhere. Future work would add to this study’s findings by focusing on the perspectives of ED physicians working in public hospitals, ED patients and their families, nurses, medical students, ED managers, and through participant observations. Second, the author did the interviews, their thematic analyses and, where needed, their translation into English. The problems associated with this design were minimised by member checking the themes highlighted in earlier interviews with subsequent participants. Not having an ED clinician as a coinvestigator both allowed a larger pool of eligible participants and likely encouraged the respondents to express their views more freely. Translations were much less of a problem because English is the primary language of medical education and clinical work in Pakistan. Respondents, therefore, even when speaking in Urdu, mostly used categories and concepts that were easily translatable into English. Nevertheless, the study also has several important strengths. It is one of the few studies from low-income and middle-income countries that have looked at providers’ perspectives on the ethical challenges faced by ED physicians. While a few studies have used healthcare providers’ narratives to understand common ethical challenges faced in clinical practice, these studies have not focused on emergency physicians.25 This study also demonstrates the use of focusing on providers’ narratives to contextualise and add nuance to the literature on clinical ethics. Everyday work in the ‘local moral world’ of an ED poses frequent ethical challenges for physicians. While these challenges probably vary depending on the cultural, economic and clinical context, the necessity to deal with them consistently and effectively remains essential for good clinical practice. Work on identifying these challenges and how best to respond to them is still nascent. This study takes a step in that direction by presenting the perspectives of ED physicians practicing in Pakistan regarding what they find ethically challenging in their clinical experiences. Acknowledgements The author acknowledges helpful feedback from Dr Junaid A Razzak and Dr Uzma R Khan on an earlier version of this research. He is also grateful to Shumaila Rupani and Nishi Shakil for help with transcription; to the physicians and residents in the Department of Emergency Medicine, Aga Khan University, Karachi, for their participation in this study; and to the two anonymous reviewers for their helpful feedback. The content is solely the responsibility of the author and does not represent the official views or policies of the Department of Emergency Medicine or the Aga Khan University.
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Contributors WZ designed the study, obtained approvals, conducted interviews, translated transcripts, did the analyses, wrote the manuscript, approved the final version and takes responsibility for the paper as a whole. Competing interests None. Ethics approval The ethical review committee of the Aga Khan University. Provenance and peer review Not commissioned; externally peer reviewed.
REFERENCES 1 2
3
4 5 6 7 8 9 10 11 12 13 14 15 16 17
18 19 20 21 22
23
24
25
Moskop JC. Informed consent in the emergency department. Emerg Med Clin North Am 1999;17:327–40. Larkin GL, Marco CA, Abbott JT. Emergency determination of decision-making capacity: Balancing autonomy and beneficence in the emergency department. Acad Emerg Med 2001;8:282–4. Moskop JC, Marco CA, Larkin GL, et al. From Hippocrates to HIPAA: privacy and confidentiality in emergency medicine-part II: Challenges in the emergency department. Ann Emerg Med 2005;45:60–7. Jecker NS, Schneiderman LJ. When families request that ‘everything possible’ be done. J Med Philos 1995;20:145–63. Marco CA, Larkin GL, Moskop JC, et al. Determination of “futility” in emergency medicine. Ann Emerg Med 2000;35:604–12. Quill TE. Initiating end-of-life discussions with seriously ill patients: addressing the “elephant in the room”. JAMA 2000;284:2502–7. Fins J, Miller FG, Bacchetta MD. Clinical pragmatism: a method of moral problem solving. Kennedy Inst Ethics J 1997;7:129–43. Kaldjian LC, Weir RF, Duffy TP. A clinician’s approach to clinical ethical reasoning. J Gen Inter Med 2005;20:306–11. Rhodes R, Alfandre D. A systematic approach to clinical moral reasoning. Clin Ethics 2007;2:66–70. Santen SA, Hemphill RR. A window on professionalism in the emergency department through medical student narratives. Ann Emerg Med 2011;58:288–94. Arnold JL. International emergency medicine and the recent development of emergency medicine worldwide. Ann Emerg Med 1999;33:97–103. Arnold JL, Dickinson G, Tsai MC, et al. A survey of emergency medicine in 36 countries. CJEM 2001;3:109–18. Corley MC, Elswick RK, Gorman M, et al. Development and evaluation of a moral distress scale. J Adv Nurs 2001;33:250–6. Kalvemark S, Hoglund AT, Hansson MG, et al. Living with conflicts-ethical dilemma and moral distress in the health care system. Soc Sci Med 2004;58:1075–84. Yang LH, Kleinman A, Link BG, et al. Culture and stigma: adding moral experience to stigma theory. Soc Sci Med 2007;64:1524–35. Kleinman A. Moral experience and ethical reflection: Can ethnography reconcile them? A quandary for “the new bioethics”. Daedalus 1999;128:69–97. Corbin J, Strauss A. Basics of qualitative research: techniques and procedures for developing grounded theory. 3rd edn. Thousand Oaks: SAGE Publications, Inc, 2007. Guest G, Bunce A, Johnson L. How many interviews are enough? An experiment with data saturation and variability. Field Methods 2006;18:59. Beoije H. A purposeful approach to the constant comparative method in the analysis of qualitative interviews. Qual Quant 2002;36:391–409. Turner L. Bioethics in a multicultural world: Medicine and morality in pluralistic settings. Health Care Anal 2003;11:99–117. Orona C, Koenig B, Davis A. Cultural aspects of nondisclosure. Camb Q Healthc Ethics 1994;3:338–46. Lapine A, Wang-Cheng R, Goldstein M, et al. When cultures clash: physician, patient, and family wishes in truth disclosure for dying patients. J Palliat Med 2001;4:475–80. Schneidermann LJ, Gilmer T, Teetzel HD, et al. Effect of ethics consultations on nonbeneficial life-sustaining treatments in the intensive care setting. JAMA 2003;290:1166–72. Zafar W, Siddiqui E, Ejaz K, et al. Health care personnel and workplace violence in the emergency departments of a volatile metropolis: Results from Karachi, Pakistan. J Emerg Med 2013;45:761–72. Sorlie V, Forde R, Lindseth A, et al. Male physicians’ narratives about being in ethically difficult care situations in paediatrics. Soc Sci Med 2001;53:657–67.
Zafar W. Emerg Med J 2015;32:263–268. doi:10.1136/emermed-2014-204081
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Moral experience and ethical challenges in an emergency department in Pakistan: emergency physicians' perspectives Waleed Zafar Emerg Med J 2015 32: 263-268 originally published online September 18, 2014
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