Caring for older patients with reduced decision-making capacity: a deductive exploratory study of ambulance clinicians’ ethical competence

Abstract

Background As more people are living longer, they become frail and are affected by multi-morbidity, resulting in increased demands from the ambulance service. Being vulnerable, older patients may have reduced decision-making capacity, despite still wanting to be involved in decision-making about their care. Their needs may be complex and difficult to assess, and do not always correspond with ambulance assessment protocols. When needing an ambulance, older patients encounter ambulance clinicians who are under high workloads and primarily consider themselves as emergency medical care providers. This situates them in the struggle between differing expectations, and ethical conflicts may arise. To resolve these, providing ethical care, focussing on interpersonal relationships and using ethical competence is needed. However, it is not known whether ambulance clinicians possess the ethical competence required to provide ethical care. Thus, the aim of this study was to deductively explore their ethical competence when caring for older patients with reduced decision-making ability. Methods A qualitative deductive and exploratory design was used to analyse dyadic interviews with ambulance clinicians. A literature review, defining ethical competence as comprising ethical sensitivity, ethical knowledge, ethical reflection, ethical decision-making, ethical action and ethical behaviour, was used as a structured categorization matrix for the analysis. Results Ambulance clinicians possess ethical competence in terms of their ethical knowledge, highlighting the need for establishing an interpersonal relationship with the older patients. To establish this, they use ethical sensitivity to interpret the patients’ needs. Doing this, they are aware of their ethical behaviour, signifying how they must act respectfully and provide the necessary time for listening and interacting. Conclusions Ambulance clinicians fail to see their gut feeling as a professional ethical competence, which might hinder them from reacting to unethical ways of working. Further, they lack ethical reflection regarding the benefits and disadvantages of paternalism, which reduces their ability to perform ethical decision-making. Moreover, their ethical knowledge is hampered by an ageist approach to older patients, which also has consequences for their ethical action. Finally, ambulance clinicians show deficiencies regarding their ethical reflections, as they reflect merely on their own actions, rather than on their values.

A bioethical perspective on the meanings behind a wish to hasten death: a meta-ethnographic review

“…Indeed, adequate communication and empathy are crucial to patients with a desire to die as they empower their autonomy and address their unique needs (dignity) and preferences [ 6 , 8 , 52 ]. Discussing end-of-life options can reduce patients and families’ anxiety and uncertainty (which increase their vulnerability), helping them to feel empowered in making decisions (autonomy) and promoting a sense of dignity [ 47 , 54 , 56 , 61 , 66 , 85 , 86 ]. In fact, evidence suggests that patients and families often have ethical concerns, which they would like to openly discuss with their attending clinicians, expecting them to be receptive and attentive to having such conversations [ 87 ].…”

Ethics rounds in the ambulance service: a qualitative evaluation

“…At the same time, these insights created new ambitions and mental tools for their continued work as ambulance clinicians. In line with these experiences, earlier research describes a compassionate approach, one that includes listening and adhering to patients’ and other colleagues’ thoughts, to indicate the presence of an ethical competence [ 7 ].…”

“…Simultaneously, the emergency medical services in many western countries are facing an increasing number of frail older patients [ 3 – 5 ]. In order to cope with an increasing proportion and variety of ethical dilemmas, the ambulance clinicians’ ethical competence appears to be increasingly important [ 6 ], however, sometimes this ethical competence is lacking [ 7 ]. Consequently, it is important to support the clinicians’ abilities and development in ethical competence, which may be achieved, e.g., by introducing ethics rounds ( 8 – 9 ).…”