Manual of First Aid Professional English: Part 1

Unit 1

Ethics and Law in Paramedic Practice

Text 1

Ethics is the field relating to right and wrong, duty and obligation, principles and values, and character. Morals refer to social standards or customs, or dealing with what is right or wrong in a practical sense. Ethical decisions are based on an appraisal of moral judgements; this idea places the responsibility on individuals.

The notion of ethics dates back to the ancient Greek philosophers. These philosophers turned the Greek focus towards questions of ethics and virtues (how one should live). These philosophers laid the basis for a science of medical ethics (bioethics), the analysis of choice in medicine. Bioethics includes moral vision, decisions, conduct, and policies of the life sciences and healthcare.

One can make many ethical and other value choices instinctively. One makes these choices by drawing on long-standing personal beliefs, commitments, and habits. For example, most people believe it is wrong to steal, to be deceitful, or to commit murder.

In healthcare, however, paramedics are faced with life issues that involve a patient. The patient may have beliefs, commitments, and habits that are different from the paramedic’s personal experience.

Throughout history, guidance in these situations has been provided through a variety of professional codes. These codes represent the collective wisdom of a group. For the paramedic, this code must take into account professional, legal, and moral responsibility.

Box 1

The Standards of Conduct, Performance, and Ethics You Must Keep

Translation 1

Duty and obligation; principles and values, character; appraisal of moral judgements; medical ethics; decisions, conduct; personal belief, personal conduct; to steal, to be deceitful, to commit murder; professional codes; take into account professional, legal, and moral responsibility; act in the best interests of patients; respect the confidentiality; personal conduct, provide any important information; knowledge, skills, and experience; communicate properly and effectively; to carry out tasks; get informed consent; keep accurate records; behave with honesty and integrity.

Text 2

Ethical Principles

There are a number of ethical principles on which ethical healthcare is based. These principles are beneficence, non-maleficence, self-determination/respect for autonomy, justice, as well as principles connected with professional–patient relationships, such as confidentiality, advocacy, veracity, and fidelity.

Beneficence

The paramedic should strive to do the very best for the patient. It suggests acts of kindness and mercy and is seen to be altruistic. However, one might question how what is best for the patient is determined. Furthermore, to what extent must paramedics strive to do good? Is there an end point? Lastly, beneficence for one patient may lead to disadvantageous care for another.

Non-Maleficence

Non-maleficence is the principle of doing no harm (primum non nocere). This is related to the principle found in the Hippocratic oath. The aim is that foreseeable harm is avoided by any action (or omission) of the paramedic.

Autonomy and Self-Determination

Autonomy originates from the Greek: auto (self) nomos (rule). It is related to the capacity to think, decide, and act freely and without adverse influence or coercion—the freedom to choose. A number of elements are required for effective self-determination: capacity, information, and voluntariness.

Capacity is the ability of the patient to think through and reason a decision; many things might influence this ability, such as age, cognitive development, the patient’s comprehension of any consequences, as well as the influence of physical changes caused by disease or medications, for example.

The paramedic must ensure the quality of the information and that the information is accurate and relevant. It is also important that the patient has an appreciation of the consequences of their decision-making; this is sometimes difficult as emergency care is unpredictable and patient outcomes vary.

It is also important that the patient has a true and accurate understanding of the information; this can be very difficult in normal circumstances and even more so in stressful or unusual emergency situations. The timing needs to be considered, and it may also be about repetition to ensure the factors discussed above are reliably in place. The information giver must have an in-depth understanding of the situation.

Finally, the third aspect that must be in place is the notion of voluntariness. This is the sense that the patient is not coerced or persuaded into making a decision that they would otherwise have not made. In practice, however, this is difficult as there may be situations where the notion of ‘duty of care’ is in the paramedic’s mind and concern about the consequences of the patient’s action (or non-action) weigh heavily.

Mostly, coercion and persuasion occur when the best interests of the patient are being considered and are being done for arguably noble reasons. This is considered in many cases to be paternalistic.

This puts the paramedic in a difficult position as the notion of patient advocacy and the paramedic being the patient’s advocate are also keys in professional practice.

Translation 2

Ethical principles; beneficence, kindness, mercy; strive to do good; non-maleficence principle; principle of doing no harm; Hippocratic oath; foreseeable harm; omission; autonomy and self-determination; think, decide, and act freely; without adverse influence or coercion; freedom to choose, decision-making; influence capacity, understanding; age, cognitive development; comprehension of any consequences; information should be accurate, true, and relevant, consider timing, repetition; notion of voluntariness; patient advocacy; paternalistic attitude; patient care in the field; ultimate responsibility; give directions; breach of duty; consent expressed, implied, assumed; emergency intervention; complete medical history; the chief complain; estimated time of arrival.

Text 3

Justice

Justice is a principle that dictates that actions by paramedics should be fair and just. When giving thought to whether an action is fair or not, the notion of best interest comes into play, the fair action may be about doing the greatest good for the greatest number.

Confidentiality

Confidentiality is both an ethical and legal element and has been deeply embedded into healthcare ethics.

Advocacy

Advocacy relates to the paramedic being focused to the needs of the patient and being their ‘advocate’. This means that the paramedic might have to support a patient in making a decision and provide care to the very highest standards possible.

Veracity and Fidelity

Veracity and fidelity are principles which relate to personal and professional integrity and the ability to be honest and truthful beyond any doubt.

A Rapid Approach to Emergency Ethical Problems

A method of ethical case analysis has been designed which works as a way to deal with emergency ethical problems rapidly. This rule-of-thumb process involves the following steps:

Ask yourself if you have experienced a similar ethical problem in the past. If so, use that experience.

If you have not experienced a similar ethical problem in the past, buy time for consulting with co-workers and other healthcare professionals.

If there is no option to buy time for deliberation, use a set of three tests:

Test 1: impartiality test—would you accept the action if you were in the patient’s place?

Test 2: universalizability test—would you feel comfortable having this action performed in all relevantly similar circumstances?

Test 3: interpersonal justifiability test—are you able to provide good reasons to justify and defend your actions to others?

If the paramedic can answer all three tests in the affirmative, then the paramedic has a fair probability that the action falls within the scope of being ethically acceptable.

Even though there may be disagreement about a specific set of values, there often is general agreement over what may comprise wrong actions.

Ethical Tests in Healthcare

The most basic question of ethical tests in healthcare is, ‘What is in the patient’s best interest?’ However, doing what is best, or what one thinks is best, is not enough to justify actions.

One must determine what the patient wants. The paramedic can do this using statements by the patient (if the patient is mentally competent) and written statements. Family input is also helpful (if the patient shows altered mental status or incompetence).

The global concept of healthcare (providing patient benefit and avoiding harm) recognizes and respects the patient’s autonomy.

The concept also recognizes the various legal issues that affect the delivery of healthcare.

Resolving Ethical Dilemmas

At times, resolving ethical dilemmas can be difficult. This may be the case when global concepts of healthcare are in conflict.

The role of the healthcare community in resolving these conflicts is to set standards of care. The role of the public in managing ethical conflicts in medicine includes creating laws and setting public policy.

Ethical Issues in Contemporary Paramedic Practice

Paramedics will face some ethical issues during the span of their careers. Most issues deal with the patient’s right to self-determination and the paramedic’s duty to provide patient care.

The paramedic should answer the following ethical questions:

What is in the patient’s best interest?

What are the patient’s rights?

Does the patient understand the issues at hand?

What is the paramedic’s professional, legal, and moral accountability?

Translation 3

Do the greatest good for the greatest number of patients; confidentiality; veracity, fidelity, professional integrity; impartiality, universalizability, justifiability; answer in the affirmative, defend your actions; general agreement; altered mental status or incompetence; the patient’s rights, legal issues, accountability; contemporary paramedic practice; allegations, durable power of attorney; do not resuscitate order; negligence, intentional abandonment; shift is over; ensuring appropriate care for the patient.

Text 4

Allocation of Resources

Fairness in the allocation of resources and obligations is a commonly accepted bioethical value. This perceived right to universal access to an adequate level of healthcare is a complex economic issue.

Two factors affect true parity in the allocation of resources. The first is a person’s ability to access healthcare. This may define what medical services are covered or excluded. The second is treatment decisions made when resources are inadequate to meet patient care needs. This may occur, for example, during a major incident or multi-casualty emergency. Allocation can pose ethical dilemmas in prehospital care.

Decisions Surrounding Resuscitation

Advance directive/decisions, so-called living wills, and other self-determination documents can help the paramedic. The paramedic can use these documents to make decisions about the appropriateness of resuscitation in the prehospital setting.

Professional Accountability

As professionals, paramedics conform to a standard set by their level of training/education and professional practice. Paramedics are accountable to the patient, their registrant body, as well as their employing ambulance service for meeting the required standards of care. Duties include commitment to high-quality patient care, continuing education, skill proficiency, and registration.

Legal Accountability

Through patient care the paramedic also assumes a role in the healthcare legal system. The paramedic should consider the importance of legal accountability as it relates to medical ethics and abide by the law when ethical conflicts occur.

Moral Accountability

Combining moral, legal, and professional accountability may be difficult in an emergency. When dealing with ethical questions, the paramedic should remember the following key points:

Emotion may not be a reliable determinant for ethical decision-making. One should monitor the conscience. Rational decision-making is making decisions that rely on research and prudence regarding what is right.

Decisions must not be based solely on the opinions of others. If paramedics come across a situation that they have never dealt with before, it is possible they might make a poor, or even unethical, decision. In these cases, paramedics should consult with other (more senior) colleagues, a supervisor, or other healthcare professionals. At times, input from patients and their loved ones can be a key source of information and can lead to a better decision.

Once the ethical question has been answered, the answer becomes a rule to guide behaviour. Once the rule has been identified, it should become a barrier to acting in opposition to the rule. Paramedics are expected not to break the rule without a strong reason for their actions.

Healthcare providers are accountable for personal and professional actions and decisions. Seeking counsel and guidance with such decisions is always wise.

Most persons are seen as having a basic right to privacy. The principle of confidentiality refers to one’s private and personal information. This information should not be disclosed by a healthcare worker to other persons without the patient’s consent.

In some cases, the release of such information is required by law. Competent patients have a legal right to decide on the healthcare they will receive. Cases in which patients refuse life-saving care can produce legal and ethical conflicts.

Translation 4

Parity in the allocation of resources; medical services covered or excluded; major incident, multi-casualty emergency; appropriateness of resuscitation; abide by the law; break the rules; combining moral, legal, and professional accountability; consult with other healthcare professionals; right to privacy; reveal private information without the patient’s consent; right to refuse life-saving care.

Text 5

Other Ethical Principles for Patient Care Situations

Care in Futile Situations

An action is seen as futile if it serves no purpose or is totally ineffective. When a paramedic is providing care in a case that may be futile, the paramedic should follow current guidelines.

An example of a futile situation in healthcare is continuing resuscitation initiated by bystanders when the patient clearly has expired. Another example is providing life support measures for a patient who has fatal injuries.

The definition of futility may pose an ethical dilemma. This may be especially true when a dispute or lack of agreement exists about the goals of treatment.

Not all futility judgements are controversial. For example, cardiopulmonary resuscitation is futile and should not be provided to patients with obvious signs of death. Some obvious signs are decapitation, rigor mortis, tissue decompensation, or extreme dependent lividity.

Obligation to Provide Care

In the prehospital arena, the patient’s request for emergency service presents a legal duty to act to the paramedic and the service as an organization.

There is no specific obligation to provide care when off duty, but if the paramedic did undertake care, he or she would be covered by the principle of Good Samaritan laws as long as the care given was in keeping with levels of skills and competence and did not fall outside of any other policies or procedures.

Patient Advocacy and Paramedic Accountability

While providing care, the paramedic serves as the patient’s advocate. Examples of ways in which a paramedic can serve as the patient’s advocate include the following:

educating patients on the delivery of healthcare

ensuring that healthcare decisions are made by patients and their doctors and are based on the medical needs of patients

informing patients of national healthcare reform initiatives

promoting patient access to reliable information about state-of-the-art medical technologies and treatments.

Paramedic–Patient Relationships

The relationship formed between the paramedic and the patient during a patient care encounter is a legal one, and therefore, legal issues may arise from providing patient care. These issues include accountability, consent, confidentiality, and those related to transportation.

Accountability

Definitions might include the notions of responsibility, answerability, culpability, liability, obligation, and duty. Paramedics are not different from other healthcare professionals in having codes to conduct that explicitly refer to the issues around accountability.

Scope of Practice

Scope of practice refers to the range of duties and skills that a paramedic is allowed and expected to perform when needed. Scope of practice defines the boundaries between the paramedic and the lay person. It also defines the boundaries between different professionals’ skills levels.

The four main arenas through which paramedics face accountability for their actions are criminal law, civil law, employment law, and through professional registration.

Most failures in care most often result in civil action rather than criminal action. Negligence has to be proven, and for this to occur, a number of elements have to be determined:

there is a duty of care

there has been a breach of that duty of care

this was reasonably foreseeable

and that it resulted in harm.

Consent

The legal principle of consent is central to any encounter with a patient in the day-to-day work of a paramedic. To avoid a charge of trespass to the person, paramedics need to obtain consent prior to patient contact, such as examination or clinical care of a patient. This will then avoid the risk of being accused of battery or assault.

Consent may be given in two forms: expressed or implied. Expressed consent may be given in writing or verbally and implied suggests that it might be by non-verbal communication or action. Consent in writing is less common in prehospital care. Most commonly, expressed consent is obtained verbally.

The patient must be able to comprehend the information, especially any consequences, and be able to use information in the decision-making process. The paramedic must assess the patient’s capacity, which might be affected by, for example, pain, panic, confusion, medication, or fatigue.

However, incapacity must not be confused with an informed choice to decline treatment. Such decisions may be based on the patient’s own beliefs and values, even if they appear irrational to us.

There are different types of incapacity, including temporary and fluctuating. In this situation, unless a valid advance refusal exists, the law permits interventions, which are necessary but no more than reasonably required in the patient’s best interests.

If the incapacity is long-standing, it is lawful to carry out procedures in the patient’s best interest, which might include wider care, not just life-saving interventions. However, in prehospital care this scenario is uncommon.

Another component for valid consent is sufficient information (information giving). This would include the nature and purpose of the procedure or action, in a way which is clear, unambiguous, balanced, and free of jargon.

The ability of the paramedic to provide accurate information is key; in other words the knowledge regarding the risks and benefits of any proposed procedure must be present.

Additionally the paramedic should have the ability to convey information to patients both clearly and concisely, to be able to ensure patients have understood the information, and to be prepared to support the patient’s decisions. So a person’s consent must be based on appropriate understanding and the patient must be intentionally giving permission for the intervention.

Translation 5

Care in futile situations, it serves no purpose or is totally ineffective; follow current guidelines; fatal injuries; obvious signs of death; decapitation; decompensation, lividity; obligation to provide care; delivery of healthcare; promoting patient access to reliable information; responsibility, answerability, culpability, liability, and duty; scope of practice; boundaries between the paramedic and the lay person; criminal law, civil law, employment law; responsibility, answerability, culpability, liability, and duty; result in harm; trespass to the person; to obtain consent prior to patient contact; be accused of battery or assault; consent may be given in writing or verbally; comprehend the information; assess the patient’s capacity, which might be affected by, for example, pain, panic, confusion, medication, or fatigue; to decline treatment; incapacity temporary, fluctuating, long-standing; carry out life-saving interventions; explain the nature and purpose of the procedure or action; way which is clear, unambiguous, balanced, and free of jargon; consent must be based on appropriate understanding; permission for the intervention.

Text 6

Voluntariness

This is the principle that consent must be voluntary and freely given, without pressure or coercion to either agree to or refuse treatment. Coercion may arise from various sources, for example, from practitioners or family. However, coercion must not be confused with information giving and ensuring benefit/risk aspects are clear.

There are difficulties that are peculiar to the prehospital environment that can influence the obtaining of consent; patients, as well as relatives and others, are likely to be stressed or anxious. There may be a lack of understanding or forgetfulness.

Paramedics operate in all sorts of environments and a possible lack of privacy may affect the initial paramedic–patient relationship. The patient may feel helpless and unable to assert themselves. Often, the patient’s health history is unknown. Other issues such as practitioner knowledge and on-scene time pressures may also provide difficulties.

Persons aged 18 years and over who have capacity are deemed in law to have the right to refuse treatment and assessment.

Full documentation must be undertaken in all situations whether a patient refuses assessment or treatment.

Where possible, obtain the patient’s signature and those of witnesses. It is very important that the patients understand the consequences of their decision and also that it is emphasized that they are perfectly entitled to change their minds; if so, then the offer of care will remain.

Equally, consent may be withdrawn at any time by the patient and the paramedic must respect the patient’s wishes. Withdrawal of consent carries the same weight in law as initial refusal to consent.

Confidentiality

Maintaining the confidentiality of patient health information is a fundamental duty, not only from a legal perspective but also an ethical one. Much sensitive information can be obtained by paramedics, and extreme care must be taken to uphold the principles of confidentiality.

Patients and the public have a right and an expectation that information about themselves will be held in an appropriate way and that respect for privacy will be upheld.

The transfer of information is considered disclosure, and this disclosure should only be undertaken when it is correct to do so.

Patients will expect that those who receive that information will be only those who are caring for the patient and have a right to that information, for that purpose.

Paramedics work in public areas, and they must be careful that confidentiality is maintained at all times; taking a history in front of bystanders or even family could put practitioners in a difficult position.

Care must be taken that copies of patient report forms are not left in public view or where they could be accessed by unauthorized persons.

Protect relates to caring for the patient’s information, inform relates to the patient being advised how other information will be used, and providing choice is allowing the patient to determine how and if disclosure of information is undertaken.

Advanced Directives

Living wills, advanced statements, advanced refusals, and do-not-resuscitate orders are collectively known as advanced directives. These are (usually) written documents that identify the patient’s wishes in the event of their death or incapacity.

Many advance refusals/decisions relate to withholding resuscitation attempts in the event of cardiac or respiratory arrest. To be valid, they must be made by the patient when they have full capacity and must be very specific about the intervention(s) being refused.

The refusal should be in writing. Certain criteria need to be in place: the patient has to be 18 years or older, has to specify the treatment to be refused, has to specify when this refusal would take place, and has to confirm that the decision is made of their own free will without coercion or influence of others.

However, if there is any doubt about the validity of the decisions, then paramedics should commence normal care and seek advice, for example, from the patient’s GP or from more senior colleagues.

Translation 6

Voluntariness; without pressure or coercion; difficulties that can influence the obtaining of consent; lack of privacy, time pressures; the patient may feel helpless; obtain the patient’s signature and those of witnesses; patients are perfectly entitled to change their minds; consent may be withdrawn at any time by the patient; respect the patient’s wishes; confidentiality of patient health information; uphold the principles of confidentiality; disclosure of sensitive information; information accessed by authorized persons only; directives, statements, refusals; in the event of their death or incapacity; in the event of cardiac or respiratory arrest; withholding resuscitation; if there is any doubt about the validity of the decisions commence normal care.

Recognition of Life Extinct (ROLE)/Futile Resuscitation

The recognition of life extinct (ROLE) guidelines are part of the clinical practice guidelines. Paramedics should familiarize themselves with the practice in their own area.

In the event of ROLE being declared, it is important that paramedics follow their service requirements for document completion and that the time of death is noted.

Staff may be required to liaise with the coroner’s office, depending on the nature of the case, and if there are any suspicious circumstances or the death is sudden and unexpected, then the police will normally become involved anyway.

If there are any factors that suggest staff should commence or continue resuscitation, then this is what should happen. These are difficult situations to deal with, especially with a distraught family present, but paramedics must be very clear about what the policies and procedures are and try to avoid any on-scene disagreements with the patient’s family.

Box 2

Physiological Changes That Occur after Death

Translation 7

Recognition of life extinct; futile resuscitation; note the time of death; liaise with the coroner’s office; suspicious circumstances, the death is sudden and unexpected; to avoid any on-scene disagreements with the patient’s family; physiological changes that occur after death; skin becomes pale and yellowish, body temperature falls; blood pressure and muscle tension decrease, and the pupils become dilated; dependent lividity, muscle stiffening; rigor mortis diminishes and the body becomes flaccid; swelling and bloating become evident; acute exacerbation; establish treatment protocols; in direct accordance with the local protocol; standing order; explain the risks of refusing care; the informed refusal of competent adult.

Text 8

Legal Duties and Ethical Responsibilities

The paramedic’s legal duties are to the patient, the employer, and the public. Like other healthcare professionals, in addition to legal duties, paramedics have ethical responsibilities that include the following:

responding with respect to the physical and emotional needs of every patient

maintaining mastery of skills and competence

participating in continuing education/refresher training

critically reviewing performance and seeking improvement

reporting honestly

respecting confidentiality

working cooperatively and with respect for other emergency workers and healthcare professionals

staying current with new concepts and modalities.

The Coroner

Deaths are reported to the coroner when, for instance, the death was through an accident, during surgery or before recovery from an anaesthetic; or where the death is unnatural, sudden, and unexplained; or from a violent cause.

The coroner may require a post-mortem examination and, depending on the result of this, may order an inquest. The inquest is likely to be called where the death was unnatural or violent, or if it occurred in prison or in the police custody, or where after the post-mortem the cause is still unclear.

Ambulance staff may be called to give evidence at a coroner’s inquest. The purpose of the inquest is to establish the identity of the deceased and the time and circumstances of the death. The coroner will examine under oath all those who provide evidence in relation to the case.

Documentation and statements may be called upon. The witnesses may be questioned by legal representatives appointed by the family, for instance, or certain other interested persons who the coroner may notify to attend the inquest.

Translation 8

Respect to the physical and emotional needs of every patient; continuing education, refresher training; deaths are reported to the coroner; death was through an accident, during surgery, or before recovery from an anaesthetic; death is unnatural, sudden, and unexplained or from a violent cause; require a post-mortem examination, order an inquest; prison, police custody; establish the identity of the deceased and the time and circumstances of the death; examine under oath; provide evidence in relation to the case; question witnesses; legal representatives appointed by the family.

Exercise A

Match the descriptions in column A with the expressions in column B to give correct keyword characteristics.

A

Creating apprehension or unauthorized handling and treatment of a patient

Physical contact with a person without consent and without legal justification

The systematic study of moral dimensions, including moral vision, decisions, conduct, and policies of the life sciences and healthcare

The discipline relating to right and wrong, moral duty and obligation, moral principles and values, and moral character; a standard for honourable behaviour

Verbal or written consent to the treatment

The presumption that an unconscious or incompetent person would consent to life-saving care

Consent obtained from a patient after explaining all facts necessary for the patient to make a reasonable decision

Social standards or customs; dealing with what is right or wrong in a practical sense

Failure to use such care as a reasonably prudent emergency medical services provider would use in similar circumstances

Conduct that fails to comfort to moral principles, values, or standards

B

a) implied consent

b) assault

c) ethics

d) bioethics

e) battery

f) informed consent

g) unethical

h) morals

i) expressed consent

j) negligence

Exercise B

Try to learn by heart:

Ethics is the discipline relating to right and wrong, moral duty and obligation, moral principles and values, and moral character. Bioethics is the science of medical ethics. Morals refer to social standards or customs.

Paramedics must meet a standard established by their level of training and regional practice.

Paramedics must abide by the law when ethical conflicts occur.

A paramedic must act in a way that is seen as morally acceptable.

The rapid approach to ethical issues is a process. The process involves reviewing past experiences, deliberation (if possible), and performing the impartiality test, universalizability test, and interpersonal justifiability test to reach an acceptable decision.

Two concepts of ethical healthcare are to provide patient benefit and to do no harm.

All resources must be allocated fairly. This is an accepted bioethical value.

Advance directives, living wills, and other self-determination documents can help the paramedic to make decisions about the appropriateness of resuscitation in the prehospital setting.

A healthcare professional is not allowed to reveal details supplied by the patient to others without the patient’s consent. This is the principle of confidentiality.

In some cases, patients refuse life-saving care. These cases can produce legal and ethical conflicts.

Other areas that are likely to raise ethical questions in the prehospital setting include providing care in futile situations, the paramedic’s obligation to provide care, patient advocacy, and the paramedic’s role in providing advanced life support skills.

To safeguard against litigation, the paramedic must be knowledgeable of legal issues. The paramedic also must know about the effects of these issues.

Paramedics and healthcare workers may be required by law to report some cases. This is known as disclosure, and the rules relating to confidentiality allow for this.

Legal claims that are related to patient care usually result from civil claims or negligence. This refers to the failure to act as a reasonable, prudent paramedic would act in such circumstances.

Most legal authorities stress that protection against claims of negligence has three elements. The first is training. The second is competent patient care skills. The third is full documentation of all patient care activities.

Confidential information is threefold. For the most part, confidential information includes any details about a patient that are related to the patient’s history. Any assessment findings also are included. Any treatment given is included as well. Rules exist surrounding disclosure.

A mentally competent adult (an adult with capacity) has the right to refuse medical care; this is the case even if the decision could result in death or permanent disability.

A patient with capacity has certain rights. The patient has the right to decide what medical care (and transportation) to receive. This is a basic concept of law and medical practice.

Legal responsibilities for the patient continue until patient care is transferred to another member of the healthcare system (or it is clear that the patient no longer requires care).

Resuscitation issues that relate directly to EMS include withholding or stopping resuscitation, advance directives, and recognition of life extinct.

Exercise C

Prepare short dialogues:

Define ethics and bioethics

Distinguish between professional, legal, and moral accountability.

Describe the role of ethical tests in resolving ethical dilemmas in healthcare.

Discuss specific prehospital ethical issues including allocation of resources, decisions surrounding resuscitation, confidentiality, and consent.

Identify ethical dilemmas that may occur related to care in futile situations, obligation to provide care, patient advocacy, and the paramedic’s role.

Describe the principles of accountability.

Define negligence and the elements necessary for a charge of negligence to be successful.

Describe the principle of consent and the elements required when consent is sought.

Identify the principle of confidentiality.

Detail the differing forms of advance directive that might influence paramedic practice.

Solution to Exercise A

1b, 2e, 3d, 4 c, 5i, 6a, 7f, 8h, 9i, 10g

Vocabulary 1

abide /əˈbaɪd/

acceptable /əkˈsept.ə.bl ̩/

access /ˈæk.ses/

accident /ˈæk.sɪ.dənt/

accurate /ˈæk.jʊ.rət/

accused /əˈkjuːzd/

additional /əˈdɪʃ.ən.əl/

adequate /ˈæd.ə.kwət/

adjunct /ˈædʒ.ʌŋk t/

advanced /ədˈvɑːnt st/ directive /daɪˈrek.tɪv/

advanced /ədˈvɑːnt st/

adverse /ˈæd.vɜːs/

advertising /ˈæd.və.taɪ.zɪŋ/

advise /ədˈvaɪ.z/

advised /ədˈvaɪzd/

advocacy /ˈæd.və.kə.sɪ/

advocate /ˈæd.vəˌkeɪt/

affect /əˈfekt/

affirmative /əˈfɜː.mə.tɪv/

agree /əˈgriː/

agreement /əˈgriː.mənt/

allocation /ˌæl.əˈkeɪ.ʃən/

allow /əˈlaʊ/

altruistic /ˌæl.truˈɪs.tɪk/

ambulance /ˈæm.bjʊ.lənt s/

anaesthetic /ˌæn.əsˈθet.ɪk/

ancient /ˈeɪn.t ʃənt/

answerability /ˌɑːnt.sər.əˈbɪl.ə.ti/

anxious /ˈæŋk .ʃəs/

appointed /əˈpɔɪn.tɪd/

appraisal /əˈpreɪ.zəl/

appreciation /əˌpriː.ʃiˈeɪ.ʃən/

apprehension /æp.rɪˈhen.ʃən/

appropriateness /əˈprəʊ.pri.ət.nəs/

arena /əˈriː.nə/

arguably /ˈɑːg.ju.ə.bli/

arise /əˈraɪz/

arrest /əˈrest/

assault /əˈsɒlt/

assert /əˈsɜːt/

assessment /əˈses.mənt/

assume /əˈsjuːm/

at /æt/ hand /hænd/

at /æt/ times /taɪmz/

attend /əˈtend/

authority /ɔːˈθɒr.ɪ.ti/

autonomy /ɔːˈtɒn.ə.mi/

avoid /əˈvɔɪd/

balanced /ˈbæl.ənt st/

based /beɪst/ on /ɒn/

battery /ˈbæt.ər.i/

behave /bɪˈheɪv/

behaviour /bɪˈheɪ.vjə/

beneficence /bɪˈnef.ɪ.sən.ts/

beyond /biˈjɒnd/

bioethics /ˈbaɪ.əʊˌeθ.ɪks/

bloating /ˈbləʊ.tɪŋ/

bluish /ˈbluː.ɪʃ/

boundary /ˈbaʊn.dər.i/

breach /briːtʃ/

break /breɪk/ the rule /ruːl/

bystander /ˈbaɪˌstæn.dər/

capacity /kəˈpæs.ə.ti/

cardiopulmonary /ˌkɑː.di.əʊˈpʊl.mə.nə.ri/

career /kəˈrɪər/

caring /ˈkeə.rɪŋ/

carry /ˈkær.i/ st out /aʊt/

casualty /ˈkæʒ.ju.əl.ti/

cause /kɔːz/

charge /tʃɑːdʒ/

choice /tʃɔɪs/

circumstance /ˈsɜː.kəm.stɑːnt s/

civil /ˈsɪv.əl/

claim /kleɪm/

code /kəʊd/

coerce /kəʊˈɜːs/

coercion /kəʊˈɜː.ʃən/

combine /kəmˈbaɪn/

comfort /ˈkʌm.fət/

comfortable /ˈkʌmp .fə.tə.bl ̩/

commence /kəˈment s/

commit /kəˈmɪt/

commitment /kəˈmɪt.mənt/

communicate /kəˈmjuː.nɪ.keɪt/

competence /ˈkɒm.pɪ.tənt s/

competent /ˈkɒm.pɪ.tənt/

completion /kəmˈpliːʃən/

comprehend /ˌkɒm.prɪˈhend/

comprehension /ˌkɒm.prɪˈhen.t ʃən/

comprise /kəmˈpraɪz/

concept /ˈkɒn.sept/

concisely /kənˈsaɪ.sli/

conduct /kənˈdʌkt/

confidence /ˈkɒn.fɪ.dənt s/

confidentiality /ˌkɒn.fɪ.den.t ʃiˈæl.ɪ.ti/

conform /kənˈfɔːm/

confused /kənˈfjuːzd/

confusion /kənˈfjuː.ʒən/

conscience /ˈkɒn.t ʃənt s/

consent /kənˈsent/

consequence /ˈkɒnt .sɪ.kwənt s/

contemporary /kənˈtem.pər.ər.i/

content /kənˈtent/

controversial /ˌkɒn.trəˈvɜː.ʃəl/

convey /kənˈveɪ/

coroner /ˈkɒr.ə.nər/

counsel /ˈkaʊnt .səl/

co-worker /ˌkəʊˈwɜːkər/

criminal /ˈkrɪm.ɪ.nəl/ law /lɔː/

culpability /ˌkʌl.pəˈbɪl.ə.ti/

current /ˈkʌr.ənt/

customs /ˈkʌs.təmz/

deal /dɪəl/ with /wɪð/

death /deθ/

decapitation /dɪˌkæp.ɪˈteɪ.ʃən/

decay /dɪˈkeɪ/

deceased /dɪˈsiːst/

deceitful /dɪˈsiːt.fʊl/

decision /dɪˈsɪʒ.ən/

declare /dɪˈkleə/

decline /dɪˈklaɪn/

decompensation /diː.kɒm.pən.ˈseɪ.ʃən/

decrease /dɪˈkriːs/

deem /diːm/

defend /dɪˈfend/

define /dɪˈfaɪn/

deliberation /dɪˌlɪb.əˈreɪ.ʃən/

delivery /dɪˈlɪv.ər.i/

dependent /dɪˈpen.dənt/

depth /depθ/

design /dɪˈzaɪn/

determinant /dɪˈtɜː.mɪ.nənt/

determine /dɪˈtɜː.mɪn/

differ /ˈdɪf.ər/

dilated /daɪˈleɪt.ɪd/

dilemma /daɪˈlem.ə/

diminish /dɪˈmɪn.ɪʃ/

directive /daɪˈrek.tɪv/

disability /ˌdɪs.əˈbɪl.ɪ.ti/

disabled /dɪˈseɪ.bəld/

disadvantageous /ˌdɪsˌæd.vənˈteɪ.dʒəs/

disagreement /ˌdɪs.əˈɡriː.mənt/

disclose /dɪsˈkləʊz/

disclosure /dɪsˈkləʊ.ʒə/

discoloration /dɪˌskʌl.əˈreɪ.ʃən/

dispute /dɪˈspjuːt/

distraught /dɪˈstrɔːt/

doubt /daʊt/

drain /dreɪn/ away /əˈweɪ/

drain /dreɪn/

drainage /ˈdreɪ.nɪdʒ/

draw /drɔː/

duty /ˈdjuː.ti/

effectively /ɪˈfek.tɪvl.ɪ/

embedded /ɪmˈbed.ɪd/

emergency /ɪˈmɜː.dʒənt .si/

emphasize /ˈemfəˌsaɪz/

employer /ɪmˈplɔɪ.ər/

employment /ɪmˈplɔɪ.mənt/

encounter /ɪnˈkaʊn.tə/

ensure /ɪnˈʃɔːr/

entire /ɪnˈtaɪə/

environment /ɪnˈvaɪə .rən .mənt/

equally /ˈiː.kwə.li/

establish /ɪˈstæb.lɪʃ/

ethics /ˈeθɪks/

event /ɪˈvent/

evident /ˈev.ɪ.dənt/

examination /ɪgˌzæm.ɪˈneɪ.ʃən/

except /ɪkˈsept/

exclude /ɪkˈskluːd/

expectation /ˌek.spekˈteɪ.ʃən/

expected /ɪkˈspek.tɪd/

experience /ɪkˈspɪə.ri.ənts/

expire /ɪkˈspaɪə/

explicitly /ɪkˈsplɪs.ɪt.li/

expressed /ɪkˈspresd/

extent /ɪkˈstent/

extinct /ɪkˈstɪŋkt/

extreme /ɪkˈstriːm/

face /feɪs/

failure /ˈfeɪ.ljər/

fair /feə/

fairly /ˈfeə.lɪ/

fairness /ˈfeə.nɪs/

fall /fɔːl/

familiarize /fəˈmɪl.i.ər.aɪz/

fatal /ˈfeɪ.təl/

fatigue /fəˈtiːg/

fidelity /fɪˈdel.ə.ti/

finding /ˈfaɪn.dɪŋ/

flaccid /ˈflæs.ɪd/

fluctuate /ˈflʌk.tju.eɪt/

foreseeable /fɔːˈsiː.ə.bl̩/

forgetfulness /fəˈget.fʊl.nɪs/

frame /freɪm/

free /friː/

freely /ˈfriːlɪ/

fundamental /ˌfʌn.dəˈmen.təl/

furthermore /ˈfɜːðəˌmɔː/

futile /ˈfjuːtaɪl/

futility /fjuːˈtɪl.ɪ.ti/

goal /gəʊl/

good /gʊd/

gravity /ˈgræv.ɪ.tɪ/

guidance /ˈɡaɪ.dəns/

handling /ˈhænd.lɪŋ/

harm /hɑːm/

health /helθ/ care /keə/ delivery /dɪˈlɪv.ər.i/

healthcare /helθ.keə/

helpless /ˈhelp.lɪs/

honest /ˈɒn.ɪst/

honesty /ˈɒn.ə.sti/

honourable /ˈɒn.ər.ə.bl̩/

identify /aɪˈden.tɪ.faɪ/

identity /aɪˈden.tɪ.ti/

impartiality /ɪmˌpɑː.ʃiˈæl.ɪ.ti/

implied /ɪmˈplaɪd/

importance /ɪmˈpɔː.tənts/

improvement /ɪmˈpruːv.mənt/

in /ɪn/ writing /ˈraɪ.tɪŋ/

inadequate /ɪˈnæd.ɪ.kwət/

incapacity /ˌɪn.kəˈpæs.ə.ti/

incident /ˈɪn.sɪ.dənt/

include /ɪnˈkluːd/

incompetence /ɪnˈkɒm.pɪ.təns/

incompetent /ɪnˈkɒm.pɪ.tənt/

ineffective /ˌɪn.ɪˈfek.tɪv/

influence /ˈɪn.flʊ.əns/

initial /ɪˈnɪʃ.əl/

initiate /ɪˈnɪʃ.i.eɪt/

initiative /ɪˈnɪʃ.ə.tɪv/

injury /ˈɪn.dʒər.i/

inquest /ˈɪnˌkwest/

instinctive /ɪnˈstɪŋk.tɪv/

integrity /ɪnˈteɡ.rə.ti/

intentionally /ɪnˈten.ʃən.əl.ɪ/

intervention /ˌɪntəˈven.ʃən/

involve /ɪnˈvɒlv/

issue /ˈɪʃ.uː/

jargon /ˈdʒɑː.gən/

judgement /ˈdʒʌdʒ.mənt/

just /dʒʌst/

justice /ˈdʒʌs.tɪs/

justifiable /ˈdʒʌs.tɪ.faɪ.ə.bl̩/

justification /ˌdʒʌs.tɪ.fɪˈkeɪ.ʃən/

justify /ˈdʒʌs.tɪ.faɪ/

keep /kiːp/

kindness /ˈkaɪnd.nɪs/

knowledge /ˈnɒl.ɪdʒ/

knowledgeable /ˈnɒl.ɪ.dʒə.bl̩/

lack /læk/

lawful /ˈlɔː.fʊl/

legal /ˈliː.gəl/

legal /ˈliːgəl/ claim /kleɪm/

liability /ˌlaɪ.əˈbɪl.ɪ.ti/

liaise /lɪˈeɪz/

life-saving /ˈlaɪfˌseɪ.vɪŋ/

litigation /ˌlɪt.ɪˈɡeɪ.ʃən/

lividity /lɪˈvɪd.ə.ti/

living /ˈlɪv.ɪŋ/ will /wɪl/

long-standing /lɒŋ.ˈstæn.dɪŋ/

loosen /ˈluː.sən/

maintain /meɪnˈteɪn/