Managing ethical aspects of advance directives in emergency care services

Abstract

Background: In Hospital Emergency Department and Emergency Medical Services professionals experience situations in which they face difficulties or barriers to know patient’s advance directives and implement them. Objectives: To analyse the barriers, facilitators, and ethical conflicts perceived by health professionals derived from the management of advance directives in emergency services. Research design, participants, and context This is a qualitative phenomenological study conducted with purposive sampling including a population of nursing and medical professionals linked to Hospital Emergency Department and Emergency Medical Services. Three focus groups were formed, totalling 24 participants. We performed an inductive-type thematic discourse analysis. Ethical considerations: This study was approved by ethical committees of Ethical Commitee of Clínic Hospital (Barcelona) and Comittee of Emergency Medical Services (Barcelona). The participants received information about the purpose of the study. Patients’ anonymity and willingness to participate in the study were guaranteed. Findings: There were four types of barriers that hindered the proper management of patients’ advance directives in Hospital Emergency Department and Emergency Medical Services: personal and professional, family members, organisational and structural, and those derived from the health system. These barriers caused ethical conflicts and hindered professionals’ decision-making. Discussion: These results are in line with those of previous studies and indicate that factors such as gender, professional category, and years of experience, in addition to professionals’ beliefs and the opinions of colleagues and family members, can also influence the professionals’ final decisions. Conclusion: The different strategies described in this study can contribute to the development of health policies and action protocols to help reduce both the barriers that hinder the correct management and implementation of advance directives and the ethical conflicts generated.

Association between knowledge and attitudes towards advance directives in emergency services

“…However, as pointed out by Pérez [ 28 ], there was still a lack of knowledge about ADs, their registering mechanisms at a practical level, and the normative aspects that regulated them. According to a phenomenological-hermeneutic study that interviewed 24 emergency care services professionals [ 13 ], the lack of knowledge of professionals can act as a barrier and make it difficult to routinely consult ADs in the emergency services. This further emphasises the need to make efforts to raise awareness among emergency professionals of the importance of knowing and consulting patients' ADs as a central element in making decisions in accordance with the wishes and preferences of individuals and as a fundamental tool to mitigate potential ethical and legal conflicts arising from the practice of care in these situations.…”

“…Secondly, the nurses and physicians on the evening and night shifts of the emergency medical services and the emergency departments were the ones most willing to respect the ADs of the persons attended in a complex situation involving a vital risk to the person, as would be the case of cardio-respiratory arrest. This result may be explained by the lack of time and the heavy workloads to which the professionals working the morning shift are subjected, which may be a clear obstacle to respecting the wishes and preferences of the person in a situation of incapacity to make decisions [ 13 , 22 , 28 , 32 ]. This could also be explained by the fact that in the evening and night shifts there are fewer professionals to consult, so that professionals working in these shifts may find the ADs helpful to guide decision-making in difficult situations.…”

“…Previous studies have indicated that it is difficult to know patients’ preferences in emergency services. According to these studies, ignorance about ADs, registration mechanisms, and the normative aspects that regulate them, as well as the lack of skills of professionals in managing them, constitute the main factors hindering the consultation and implementation of AD in these services [ 13 , 14 ]. Likewise, in addition to posing a clear threat to respect for individuals’ autonomy of decision [ 15 ], these obstacles described in the literature can generate conflictive situations from an ethical and legal perspective [ 16 ].…”

Association Between Knowledge and Attitudes Towards Advance Directives in Emergency Services

“…However, as pointed out by Pérez et al (24), there was still a lack of knowledge about AD, their registering mechanisms at a practical level, and the normative aspects that regulated them. According to a phenomenological-hermeneutic study that interviewed 24 emergency care services professionals (11), the lack of knowledge presented by professionals can act as a barrier and make it di cult to routinely consult ADs in the emergency services. In order to overcome this barrier, the professionals interviewed considered it necessary to improve communication circuits between services and to reconvert and unify the computer programs currently used in care.…”

“…The ignorance of AD, their registration mechanisms and the normative aspects that regulate them, as well as the lack of skills of professionals to manage them, constitute the main factors that hinder the consultation and implementation of AD in these services (11,12).…”