# Refusing to provide service



## mycrofft (Nov 6, 2012)

Any thoughts about these instances?
===========================
A patient is brought to treatment with chest pain and dyspnea, and shortly thereafter loses consciousness and pulse. A team member backs away from the scene and quickly walks down the hall.

When report is begun at change of shift about a new AIDS patient and his potential for resuscitative measures, the oncoming nurse raises her hands, shakes her head, and turns and walks away.

Upon hearing that a newly-hospitalized patient may have had meningococal meningitis, three caregivers state they will not be in to work the next day...and aren't.

Caregivers are told a recent admission to their smallish facility has a haemorrhagic fever, and they walk out, leaving a handful of staff for a like number of patients, plus the unlucky recent admissions.
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Anyone ever see this sort of behavior? Anyone ever DO something like this? What were the causes? Were they justifiable?:huh:


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## Veneficus (Nov 6, 2012)

mycrofft said:


> Any thoughts about these instances?
> ===========================
> A patient is brought to treatment with chest pain and dyspnea, and shortly thereafter loses consciousness and pulse. A team member backs away from the scene and quickly walks down the hall.
> 
> ...



I have never done it, my ongoing problem with personal responsibility.

However, it is taught in medical school that if you feel you are not capable (for whatever reason) of doing your best for a patient then as long as you make sure they can get proper care, you are not obliged to care for them personally. 

A good example is abortion. 

I can't honestly speak for nurses, but I would imagine the same applies.

Also, in EMS we are taught if the scene is not safe to leave the scene. Not in all, but in some cases you cite, that could be a serious and legitimate concern.

How many hospitals do you think could properly treat and contain an ebola case? Would it be worth the risk to your person if you thought they couldn't?

In a more benign setting, who hasn't had a patient that gets on their nerves so they ask a colleague to take care of them instead?

I admit that is a bit different then leaving that colleague to take care of all patients.

Again, just my personality trait, but I am usually the one who volunteers to do the stuff others find undesirable. Like death notification. Mostly because it causes me less duress than some coworkers. 

In order for there to be abandonment, there has to be a duty to act. Which arguably doesn't exist in all aspects of medicine. 

Then there has to be a patient/provider relationship. 

Plus an actual treatment decision.

Otherwise, every surgeon who refused to take a case and operate would be doing exactly what was described above.

How much different is it really than punting a patient between services?


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## mycrofft (Nov 7, 2012)

Thanks.


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## JPINFV (Nov 7, 2012)

I had a nurse pull me aside and whisper that the patient we were discharging had AIDS. I promptly promised not to play with the patient's blood.


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## mycrofft (Nov 7, 2012)

:rofl:.....

But "bodily fluids" might have been funnier.


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## ThirdCareerMedic (Nov 9, 2012)

*Bodily fluids and ethical choices....*

I throw in my vote for bodily fluids, too!:rofl:

I have a problem with most of the examples given in the first post.  If you are there to care of patients REGARDLESS of what might ail them, then you are in the right job.  If you want to "cherry pick", then perhaps something a little less risky would be better for you....  

In the health business, we have to know how to best manage the risks with which we are faced.  In emergency medicine, it is more important that we are not risk adverse but at the same time we take all reasonable precautions.    I haven't heard of too many firefighters refusing to go into a building because it is burning.  They are trained to take carefully calculated risks not just to run away when they are afraid of the possibilities....

Just my two cents worth....  :lol:


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## mycrofft (Nov 9, 2012)

*OK, here's another piece to the puzzle*

I was witholding that all these people were either in or were born in a so-called emerging nation. How about now?


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## ThirdCareerMedic (Nov 9, 2012)

*Poorly resourced health care systems, Ethical Practice and Capacity Building....*

Well, the additional information about the examples coming from "emerging nations" DOES add something very important to the mix....

Although the code of professional ethics and my own personal moral code, would not allow me to do any of the things you mentioned, I am not in a position to sit in high and mighty judgement of people working in poorly resourced health care systems in developing/emerging nations....  If systems do not support health care workers by providing adequate resources to do their jobs, there will be problems.  All health care workers need adequate training to deal with risks and complex ethical issues;  adequate resources to ensure their physical, emotional and mental safety;  adequate staffing levels to prevent compassion fatigue; and of course adequate physical resources to do their jobs and adequate wages/salaries (or in areas of great poverty, at least survive).  

If you know of specific instances and have a personal connection, perhaps there is some way you (we) can reach out and help?  Just a thought.....


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## mycrofft (Nov 9, 2012)

Three out of four of these occurred in the US. When asked why they refused to render care, they cited that they didn't trust personal protective devices and said, in effect, "We still don't know everything about how these diseases are transmitted". ALL were licensed.


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## ThirdCareerMedic (Nov 9, 2012)

*Compassionate, ethical, professional care....*

It looks like we have a long way to go in our countries as well!  LOL!

Any ideas on how to deal with issues like this in your neck of the woods?  Any others have ideas on how to increase professionalism in paramedicine (our stomping ground!)?


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## mycrofft (Nov 9, 2012)

Thanks for remaining on the positive!
In the cases I personally saw, the answer was to find out if job applicants had these sorts of reservations, and not hire them into an environment where their failure burdened co-workers and their patients suffered. It would be like hiring someone to work at a nuclear reactor who had unreasonable fears about atomic power. They would have done better where they were not so challenged.

I talked to a couple, and it was simply a matter of faith that the germs could get them anyway or they were not supposed to touch strange dead (in CPR) people. They also had a basic absence of the concept of professional interdependency/teamwork leading to a "me-first" attitude. Nothing can trump that sort of attitude.


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## ThirdCareerMedic (Nov 9, 2012)

*Changing Attitudes....*



mycrofft said:


> Thanks for remaining on the positive!
> In the cases I personally saw, the answer was to find out if job applicants had these sorts of reservations, and not hire them into an environment where their failure burdened co-workers and their patients suffered. It would be like hiring someone to work at a nuclear reactor who had unreasonable fears about atomic power. They would have done better where they were not so challenged.
> 
> I talked to a couple, and it was simply a matter of faith that the germs could get them anyway or they were not supposed to touch strange dead (in CPR) people. They also had a basic absence of the concept of professional interdependency/teamwork leading to a "me-first" attitude. Nothing can trump that sort of attitude.



The only thing that can change attitudes is education and contact with positive role models....  Promote education and keep modeling professional, ethical, compassionate care!

Onward and upward (inside out and through?!  LOL!)!


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## mycrofft (Nov 9, 2012)

Yep. 
Now, how about excusing such actions because they are cultural instead of reasoning/science-based?

We all have such cultural bumps, but since we are embedded in our culture, we don't see them unless we move out and see it differently.


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## ThirdCareerMedic (Nov 9, 2012)

*Cultural Issues in Paramedic and Health Care Practice in General....*



mycrofft said:


> Yep.
> Now, how about excusing such actions because they are cultural instead of reasoning/science-based?
> 
> We all have such cultural bumps, but since we are embedded in our culture, we don't see them unless we move out and see it differently.




You are bringing up something very important. We all need to first recognize and become sensitive to cultural differences and then proceed to developing "cultural competencies" for paramedic practice in ethnically/culturally/socially diverse communities.  The final stop is when we have come to understand AND value (not fear!) the differences between ethnic groups/social minorities/religious groups, etc.  Then, and only then can move on to "cultural safety" and recognize how this actually increases both productivity and harmony....  Social workers, doctors and nurses have recognized embracing diversity is key in patient-centered care and ethical practice.  I think each of us need to think about the implications of this for own practice and paramedicine as we move towards recognition as profession in its own right....

(OK!  Time to get off the soap box!  LOL! )


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## JPINFV (Nov 9, 2012)

mycrofft said:


> I talked to a couple, and it was simply a matter of faith that the germs could get them anyway or they were not supposed to touch strange dead (in CPR) people. They also had a basic absence of the concept of professional interdependency/teamwork leading to a "me-first" attitude. Nothing can trump that sort of attitude.


 

Well, if CPR is in progress, just call them mostly dead.


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## ThirdCareerMedic (Nov 9, 2012)

JPINFV said:


> Well, if CPR is in progress, just call them mostly dead.



I can't believe someone got as much of a kick out of this cult classic as I did!  :rofl:


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## JPINFV (Nov 9, 2012)

ThirdCareerMedic said:


> I can't believe someone got as much of a kick out of this cult classic as I did! :rofl:


 
[Russian voice]What can I say, I like the memes. [/Russian voice]


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## ThirdCareerMedic (Nov 9, 2012)

JPINFV said:


> [Russian voice]What can I say, I like the memes. [/Russian voice]



:rofl:


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## Medic Tim (Nov 9, 2012)

JPINFV said:


> [Russian voice]What can I say, I like the memes. [/Russian voice]



Awesome


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## VFlutter (Nov 9, 2012)

In my opinion refusing to care for a patient with a communicable disease, with appropriate PPE available, is unacceptable. What did you expect when you went into the medical field? Now I am not saying go into a TB patients room with no mask but it refuse to care but refusing to take a patient with AIDS is just blatantly ignorant. 


We had a scenario in my ethics class about a hypoglycemic elderly patient who was combative and assaulted the tech who was trying to get out of bed. Out of my class (40ish) only 3 people said they would treat the patient, everyone else said they would refuse to enter the room or that they would wait for security. My favorite comment was "Assign a male nurse to the patient ".


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## ThirdCareerMedic (Nov 9, 2012)

ChaseZ33 said:


> In my opinion refusing to care for a patient with a communicable disease, with appropriate PPE available, is unacceptable. What did you expect when you went into the medical field? Now I am not saying go into a TB patients room with no mask but it refuse to care but refusing to take a patient with AIDS is just blatantly ignorant.
> 
> 
> We had a scenario in my ethics class about a hypoglycemic elderly patient who was combative and assaulted the tech who was trying to get out of bed. Out of my class (40ish) only 3 people said they would treat the patient, everyone else said they would refuse to enter the room or that they would wait for security. My favorite comment was "Assign a male nurse to the patient ".



Wow!  Did your classmates come to understand their professional ethical obligations by the end of the course?  (Hope springs eternal!  :lol


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## Veneficus (Nov 10, 2012)

ChaseZ33 said:


> We had a scenario in my ethics class about a hypoglycemic elderly patient who was combative and assaulted the tech who was trying to get out of bed. Out of my class (40ish) only 3 people said they would treat the patient, everyone else said they would refuse to enter the room or that they would wait for security. My favorite comment was "Assign a male nurse to the patient ".



I am not sure there is a problem here, if it was unsafe for a provider to enter and treat, waiting for security or refusing to put themselves in a dangerous situation seems perfectly acceptable to me.

There is not some fantastic martyrdom oaths that healthcare workers take.

When rushing in to help, if you get hurt and miss work who is paying for that?

If you are disabled, how does that affect your employability and quality of life. 

Lose an eye to treat a hypoglycemic? Not a good trade in my book.

What is safe for some may not be safe for others, but I think the idea of self sacrifice in order to provide medical care is more than a little extreme.


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## VFlutter (Nov 10, 2012)

Veneficus said:


> What is safe for some may not be safe for others, but I think the idea of self sacrifice in order to provide medical care is more than a little extreme.



Very true, I am not advocating taking huge risks but at least to me personally potentially taking a punch from a confused patient would not stop me from providing care.


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## Veneficus (Nov 10, 2012)

ChaseZ33 said:


> Very true, I am not advocating taking huge risks but at least to me personally potentially taking a punch from a confused patient would not stop me from providing care.



Make sure you don't take a head shot doing that or a floating rib


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## ThirdCareerMedic (Nov 10, 2012)

ChaseZ33 said:


> Very true, I am not advocating taking huge risks but at least to me personally potentially taking a punch from a confused patient would not stop me from providing care.



I have had to work with confused (Alzheimer's) elderly patients who were being aggressive AND needed care.  My first concern is always my and my partner's safety but when we are called out we have the duty to act and so attempt everything we could to gain the patient's cooperation.  Distraction works well in some cases and calling a trusted caregiver to calm them works in others.  It is important to get the proper training to be able to better interact with such patients AND knowing when it is futile and calling for back up.

In terms of the hypoglycemia patient,  we know that the patient needs care immediately.  We know that we can provide it but that to do so, we need to be sure we can do so without undue risk to ourselves.  There are two of us and in an institutional setting, we should be able to quickly get staff to help us humanely restrain the patient.  That may or may not be the case depending on the institution....

I work rural where we have little back up from fire, police or anyone else.  The nature of our environment makes it imperative for us to learn how to deal with aggressive/confused patients and deescalate situations as quickly and safely as possible.  In some ways, we may take more risks than urban medics.  However, they are (hopefully) calculated risks based on what we know about the community and our desire to serve it....

Any thoughts?


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## Veneficus (Nov 10, 2012)

ThirdCareerMedic said:


> In some ways, we may take more risks than urban medics.  However, they are (hopefully) calculated risks based on what we know about the community and our desire to serve it....
> 
> Any thoughts?



I submit you have never worked in the inner city US...

The same can be said and is true. 

There are many things that would be considered "extremely risky" to people who do not work and understand their environment. 

I have knocked on doors so people can disarm their booby trap, walk past a table full of drugs and guns to attend to the matriarch of the family whos social security cheque was supporting 3 generations in the house. Never once did we call the cops or for back-up. 

An experienced provider who understands, can work with, and manipulate their environment, while seemingly so, does not take much risk at all. 

But it is impossible with the varied provider experience and environments to make blaket statements on what is risky or not.

What I do advocate is if you are unsure, untrained, outclassed, you play it safe.

If that means a patient suffers or dies, then they do. But providers come home in the same condition they left it in. 

That is not negotiable. There are no "acceptable losses."


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## ThirdCareerMedic (Nov 10, 2012)

Veneficus said:


> I submit you have never worked in the inner city US...
> 
> What I do advocate is if you are unsure, untrained, outclassed, you play it safe.
> 
> ...



I am in full agreement with you there!


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