Patient autonomy in emergency medicine.

Theoretical models for patient-physician communication in clinical practice are frequently described in the literature. Respecting patient autonomy is an ethical problem the physician faces in a medical emergency situation. No theoretical physician-patient model seems to be ideal for solving the communication problem in clinical practice. Theoretical models can at best give guidance to behavior and judgement in emergency situations. In this article the premises of autonomous treatment decisions are discussed. Based on a case-report we discuss different genuine efforts the physician can do to uncover treatment refusal and respect patient autonomy in an emergency situation. Autonomy requires competence and in emergency medicine time does not allow intimate exploration of patient competence and reasons for treatment refusal. We find that the physician must base her decision on a firm theoretical base combined with a practical and realistic view of the patient's situation on a case to case basis.

[Euthanasia--experiences from Norwegian pain clinics]. / Eutanasi--erfaring fra norske smerteklinikker.

This survey focuses on the subject of euthanasia. A questionnaire was sent to 90 doctors working in pain clinics in Norwegian hospitals. 60 doctors (67%) returned the questionnaire. Only 18 doctors (30%) had ever received a request for euthanasia. The patients who requested euthanasia suffered from refractory pain, depression, fear of pain and fear of becoming helpless. 67% of the doctors were satisfied with the present Norwegian law, while 13% favoured a liberalization of the law. Only 5% were willing to comply with the patient's request for euthanasia under today's law. One third of the doctors would leave the decision to an officially appointed "board" if euthanasia were to become legalized. A majority wanted a doctor to commit the actual procedure, but there were also suggestions that a lawyer or other lay person should carry out the act of euthanasia. Our conclusion is that the closer the patient-doctor relationship is, the more opposed the doctor is to euthanasia.

Impact of a child first aid wall calendar on lay people's skills and knowledge of infant CPR.

The aim of the study was to evaluate whether mass-mailing of a 12-month wall calendar which focused on child and infant safety and first aid treatment had any educational effect on lay people. The calendar included algorithms for removal of a foreign body from the airways and infant and child CPR. The knowledge and skills in these procedures were tested in two groups using a previously validated check-list before and after the introduction of the calendar. One group received the calendar by mass mailing, free-of-charge. Six months after calendar distribution the mean result for 52 persons tested was 18% correct, not different from the 19% correct for 65 persons tested before calendar distribution. The other group received the calendar as part of an internal company campaign focusing on infant and child safety with a possibility for borrowing a baby manikin, but with no instruction involved. In this group the mean result improved significantly from 27% precalendar (n = 57) to 47% (n = 125) (P < 0.001) 1 week after calendar distribution with a significant reduction to 38% (n = 52) (P = 0.004) 6 months later, still significantly better than precalendar (P = 0.004). Test persons younger than 50 years old scored better than those older than 50 years (39 vs. 22%, P < 0.001), and the test persons scored better if they had been tested previously (44 vs. 35%, P = 0.04) or had practised with a baby manikin (45 vs. 35%, P = 0.02). Whether the test persons had children 0-8 years old or not, did not affect the results. In conclusion the calendar had no educational effect when distributed by mail, but a safety campaign which included distribution of the calendar and a possibility to borrow a manikin had a positive influence on the first aid skills and knowledge of lay people. Mass mailing of CPR or other first aid material free-of-charge does not seem to further the goal of increasing the rate and proficiency of bystander interventions to save lives.

Paramedics organizational culture and their care for relatives of cardiac arrest victims.

During in-depth interviews about treatment decisions made by paramedics in cases of cardiac arrest in Oslo, other aspects of their work were frequently brought up. Twenty-four of 33 paramedics emphasized the importance of taking care of bystanding relatives, and frequently spent up to 45-60 min with them after unsuccessful resuscitations. Twenty-three mentioned that they frequently were not being appreciated as health care professionals by other health care personnel. Other aspects mentioned were the relationship with colleagues, debriefing, exhaustion, burnout and little management support. Emotions were frequently exposed during the interviews, but emotions and the importance of caring for relatives (defined by the paramedics as the most important part of their work), were not recognized by the organization, which appeared to have a male 'I can cope with everything' culture. This might partly be due to a lack of appreciation by others and partly a way of coping with the stress of their job. There appeared to be a need for change towards talking about the positive value of caring, and sharing of stress and built-up tension between the paramedics, their organization and the doctors.

Intubation with laryngoscope versus transillumination performed by paramedic students on manikins and cadavers.

Seventeen paramedic students, all of whom are novice intubators, performed laryngoscopic and Trachlight intubation after supervised training for 90 min on two manikins (Laerdal, AMBU) and 30 min on cadavers. A maximum of two intubation attempts lasting a maximum 30 s each were permitted on each manikin and the cadaver. The time for confirming tube placement by auscultation and securing the tube was added. Laryngoscopic intubation was successful on cadavers and both manikins in 94-100% of the trials. Intubation with the Trachlight was 100% successful in the Laerdal manikin, but significantly lower than with the laryngoscope in the AMBU manikin (65%), and in cadavers (50%). The mean intubation time was significantly longer (30-44 s) with the Trachlight compared with laryngoscopic intubation (10-23 s) in both manikins and cadavers. The present results do not indicate that intubation with the Trachlight is an improvement upon laryngoscopic intubation for novices.

Ethics in treatment decisions during out-of-hospital resuscitation.

Paramedics in Oslo are allowed to make decisions about withholding or terminating cardiopulmonary resuscitation (CPR). In order to elicit the criteria used, 35 paramedics and nine doctors were interviewed after 70 episodes of cardiac arrest outside-of-hospital. CPR was not attempted in 21 patients, and discontinued in the field in 28 patients. Spontaneous circulation was restored in 15 patients, and six patients were transported to hospital with ongoing CPR. Both prognostic and ethical criteria were used without a clear borderline. Signs considered to indicate good prognosis such as VF, gaps, contracted pupils, or normal skin color always led to start of CPR. Bystander CPR was continued even when the professional thought the effort was futile, partly to encourage the bystanders. The social status of the patient did not affect the decisions, and advanced age only when combined with important criteria such as arrest times or the relatives' wishes. The only apparent difference between paramedics and doctors was that the reputation of the EMS system influenced only the paramedics. All paramedics had long experience which influenced their decisions, which were based on a rapidly composed broad picture of the patient's situation. All presented serious ethical considerations about life and death indicating that they did not make these decisions lightly.

[Incidence and content of written guidelines for "do not resuscitate" orders. Survey at six different somatic hospitals in Oslo]. / Forekomst og utforming av skriftlige retningslinjer for R-ordre. En undersøkelse ved seks somatiske sykehus i Oslo.

This paper presents the incidence of, and contents of guidelines for do-not-resuscitate orders (DNR orders) in somatic hospital departments in Oslo. Only five out of 14 departments had written guidelines. There was a wide range of contents concerning illness criteria, decision-making responsibility and patient and family participation in the decision-making process. We find that there is a need for written guidelines for the use of DNR orders and present a template for the appropriate use of such orders. The proper use of DNR orders will prevent futile cardiopulmonary resuscitation and hopefully bring about a discussion on the ethical aspects of treatment decisions in hospital departments.