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Monday, February 7, 2011

Patient Advocacy

What does it mean to be a patient's advocate?

The dictionary describes an advocate as "a person who speaks or writes in support or defense of a person, cause, etc."

In EMS we talk about being a patient advocate. About being the type of medical professional that will always try and do what is right for the patient. Sometimes that is respecting their wishes to not have resuscitation measures taken. Other times it is simply making sure the ER staff has heard their concerns before you leave. Every situation is different and at times it's a judgment call.

I recently read a post by a fellow blogger Michael Morse over at Rescuing Providence, where he was, in my opinion, a great patient advocate in a difficult situation. Someone left a comment on his blog tearing into him for the way he treated his patient. I think he was dead on.

You see, most of the time acting on behalf of the patient is cut and dry. You simply treat them. They don't complain because they called you and want you to treat them. However there are some times that being a patient advocate strays into a gray area. Let me give you an example, but first a little background info.

A patient, as long as he is what we call "alert and oriented" (meaning he knows where he is, what's going on and is capable of making decisions) has the ability to refuse treatment. If they are not alert and oriented then we have to assume that they would agree to whatever treatment to which your average Joe would consent. The patient loses the ability to decline treatment.

Example #1

You arrive on scene to find one of your frequent flyers. You were called because his roommate couldn't wake him up, at 1 in the afternoon. He's a 38 year old male with a history of heroine abuse. A quick assessment reveals that the patient is unresponsive and barely breathing 4 times a minute. He has snoring respirations and his pupils are pinpoint. All signs that he has had another heroine overdose. (Please assume that a thorough assessment has been done but I'm not going over everything here) The patient has a history of becoming extremely violent when he's brought out of his narcotic high.

Now there are several ways to treat this guy. If you want to start a fight, or want to give the ambulance crew a tough time, you slam in Narcan and counteract all of the heroine. This will often lead to a confrontation with the user when he realizes you just wasted his high.

Some new medics may decide to intubate the patient in an attempt to control his airway. If they go down this path there's a good chance that after they administer the Narcan the patient will rip out his ET tube and beat the medic with it.

I think the best option is to give him just enough Narcan to reverse the respiratory depression but not so much that he regains consciousness. This way you can provide adequate patient care without an altercation.

However, this is where the gray area comes in. If we reversed all the affects of the heroine the patient would no doubt become alert and oriented. If he's alert and oriented then he can legally refuse treatment. Now your patient that needs definitive care (Narcan is short lasting) is refusing to go. So do you keep him unconscious and take from him the ability to refuse care?

Example #2 

Your classic case of hypoglycemia. Someone finds the patient unresponsive and calls us. All they need is some sugar and they wake back up. 

So what's the best way to treat this patient. It totally depends on the patient.

If the patient does not have a history of diabetes you administer the glucose and then transport them to the ER. Something is causing their insulin levels to be out of whack and it needs to be diagnosed.

If the patient has a history of diabetes and just missed a meal, or something similar then I have no problem giving them some D50, then making them a sandwich and signing them out AMA. I'd like to have someone there to watch over them if possible as well. 

If 911 has been called multiple times in the last few weeks for this patient and he always signs out AMA after you administer the sugar than I'm all for getting the patient loaded up and on their way to the hospital before giving them the glucose. This way the patient will end up getting seen at the hospital where more tests can be done.

In both examples there are treatment options that do limit the patient's ability to decline treatment. Does this make it wrong? I don't think so. But part of what makes this a wonderful world is a difference of opinion. Let me know what you think. Weather you are a medical professional or not. This is more of an ethical question.


Erin said...

I'm just glad that my paying job (teaching violin) does not have to deal with these kinds of life and death situations. And I'm glad that you love your work.

Jen at Cabin Fever said...

Ugh, both situations I have been in and are always tough. I am with you... sometimes there are underlying issues that we as healthcare professionals know about and it is our duty to see that they seek treatment 'as any prudent person would'. Thankfully the law of implied consent is on our side to do so.

melaniek said...

Not having any knowledge of the finer details of informed/implied consent...I have to agree with you on both measures. To me that sounds absolutely acceptable. If I put myself in as the second patient, lol, sorry not gonna pretend to be a drug addict, and 911 had to be called for me multiple times because of hypoglycemia I would want you to do exactly as you described. I guess I figure that maybe for some reason, if I was in that situation I wouldn't be able to understand that it was vital to go be seen. So if I can't be the one to make that call...then the medic should. I totally understand the gray area though and know that not all people would share the same opinion, whatever their reason may be.

Michael Morse said...

I think we see eye to eye on this issue! And thanks for the props :)

John Michael Judah said...

I know this is an old post but if you can pleade email at id really like tonget a thrid parties look at howbwe handle a situation. Thank you.

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