# Medical Ethical Scenarios



## sirengirl

So today in class we were going over the bioethics and medical legal chapters of my AAOS textbook. Our teacher posed 3 scenarios to us, then divided the classroom in half to have each half argue for or against treatment/transport for the scenarios. They were good ones to get ya thinkin, really more on the ethical parts, so hopefully this doesn't turn into a crazy flamefest on here. These were calls all my medic instructers have actually run over the years. Please note that I am writing these down exactly as they were told to us, I don't have any vitals or patient info to give other than what's here. 

Have at it!!


Scenario 1: SNF nurse (who amazingly is calling for her patient ) calls for 90y/o male choking on a cookie in agonal resps. Upon assessment find strong carotid, unconscious, warm, and pt has a DNR for lung cancer stating no machines, CPR, or RSI. Finger sweep/Magill forceps unable to clear airway. Care about to be terminated when daughter arrives with valid paperwork verifying she is surrogate decision maker, demanding you intubate and recusitate the patient. Your medical director is well known for having a problem with intubated DNR patients. What do you do?

Scenario 2: You have just cleared a early-morning call at the end of your shift. It's 730, and you are enroute to the station to clear out for the day. Stopping at the McDonalds for some coffee, the manager approaches and tells you he has a customer who has vomited and asks if you would check them out. Begrudgingly, you do so. The patient is a 66 y/o male, vomitus evident, diaphoretic, ashen, and SOB. He is well-to-do and his wife is telling him to go to the hospital. He is telling her he won't go. After some convincing, he allows you to assess him, and discover he has audible PE with crackles and unstable vitals. 12 lead shows gross ST elevation in 3 leads, confirming AMI. Pt AOx3 and has refused transport to the point of getting angry. LEO called and will not arrest or detain the patient. Wife cannot persuade him. You and your unit tell him he will likely die if he does not go to the hospital, and he refuses. Contacting online med control, the physician tells you, "I don't care what you have to do, bring me that patient now." The patient insists that if you touch him, he will personally sue you and your partner. What do you do?

Scenario 3: 2am tones for Hospice patient in local nursing home with bowel cancer. Pt unconscious with irregular RR and unstable vitals, valid DNR. 10 family members and hospice representative present with patient. Nursing home demands you transport to the ER, as the facility has a policy forbidding patient death on premesis. Medical control also wants the patient transported to the ER with only pallative measures. Family is up in arms, stating the patient wished to die in his own bed. What do you do?


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## Handsome Robb

1) I'd call med control, stick the decision on the doctor, but If the daughter has the valid paperwork you have to do it.

2) He's A&O, if he wants to refuse care that's his right, you can't force him to do anything and the doctor can't force you to commit kidnapping. Document the heck outta his refusal and everything you did to try and change his mind.

3)Transport. Patient is alive and OMD wants him transported, if the family doesn't have correct proof of surrogate decision maker they don't really have a say in the matter, its terrible to say but it's true. Politely explain to them why you are doing what your doing. If they are getting really rowdy get PD involved, you don't want to get hurt. This is a pretty awkward position to be in.


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## JPINFV

1. In most systems (and all for power of attorney:health care or conservators), any family member can request resuscitation. In effect, once resuscitation is requested, the patient no longer has a valid DNR. 

2. If the patient is A/Ox4, understands the consequences of his actions, and understands the severity of his condition (collectively called capacity), then he can refuse care. The medical control physician cannot order you to violate the law, which forcing the patient to seek care would do. 

3. Family has the ability, again, in most systems to make medical decisions. No one is arguing that the patient is or is not a DNR. Leave them at the SNF. The SNF RN cannot force transport, thus leaving the only sticky situation to be the medical control physician.


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## sirengirl

NVRob said:


> 1) I'd call med control, stick the decision on the doctor, but If the daughter has the valid paperwork you have to do it.
> 
> 2) He's A&O, if he wants to refuse care that's his right, you can't force him to do anything and the doctor can't force you to commit kidnapping. Document the heck outta his refusal and everything you did to try and change his mind.
> 
> 3)Transport. Patient is alive and OMD wants him transported, if the family doesn't have correct proof of surrogate decision maker they don't really have a say in the matter, its terrible to say but it's true. Politely explain to them why you are doing what your doing. If they are getting really rowdy get PD involved, you don't want to get hurt. This is a pretty awkward position to be in.



Agreed on all points. On 2, however, a lot of us agreed that since we would probably then stick around McDonalds for a while- you know, have our coffee, maybe fiddle around with some things in the truck for 10 or 15 minutes - until he conks out and then grab his arse and red light outta there. Cause, y'know, then it's implied consent cause he's not awake to say otherwise


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## JD9940

NVRob said:


> 1) I'd call med control, stick the decision on the doctor, but If the daughter has the valid paperwork you have to do it.
> 
> 2) He's A&O, if he wants to refuse care that's his right, you can't force him to do anything and the doctor can't force you to commit kidnapping. Document the heck outta his refusal and everything you did to try and change his mind.
> 
> 3)Transport. Patient is alive and OMD wants him transported, if the family doesn't have correct proof of surrogate decision maker they don't really have a say in the matter, its terrible to say but it's true. Politely explain to them why you are doing what your doing. If they are getting really rowdy get PD involved, you don't want to get hurt. This is a pretty awkward position to be in.



couldnt agree more on these answers


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## Handsome Robb

sirengirl said:


> Agreed on all points. On 2, however, a lot of us agreed that since we would probably then stick around McDonalds for a while- you know, have our coffee, maybe fiddle around with some things in the truck for 10 or 15 minutes ) until he conks out and then grab his arse and red light outta there. Cause, y'know, then it's implied consent cause he's not awake to say otherwise



Some people will argue this though. He competently refused care prior to the event. We talked about this in class and I couldn't get a straight answer out of it. Lawyer said don't touch the pt unless it was a different crew who hadn't seen the pt prior to the collapse and medic instructor said unconscious pt means consent is implied.


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## sirengirl

NVRob said:


> Some people will argue this though. He competently refused care prior to the event. We talked about this in class and I couldn't get a straight answer out of it. Lawyer said don't touch the pt unless it was a different crew who hadn't seen the pt prior to the collapse and medic instructor said unconscious pt means consent is implied.



Fair point. I'm not sure what the mandate around that would be here in Florida, I'll try to remember to ask my instructor on Friday. I'd do it anyways and say, "Hey, I was there, just havin' my coffee that I went there to get anyways, and he passed out..."


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## silver

sirengirl said:


> So today in class we were going over the bioethics and medical legal chapters of my AAOS textbook. Our teacher posed 3 scenarios to us, then divided the classroom in half to have each half argue for or against treatment/transport for the scenarios. They were good ones to get ya thinkin, really more on the ethical parts, so hopefully this doesn't turn into a crazy flamefest on here. These were calls all my medic instructers have actually run over the years. Please note that I am writing these down exactly as they were told to us, I don't have any vitals or patient info to give other than what's here.
> 
> Have at it!!
> 
> 
> Scenario 1: SNF nurse (who amazingly is calling for her patient ) calls for 90y/o male choking on a cookie in agonal resps. Upon assessment find strong carotid, unconscious, warm, and pt has a DNR for lung cancer stating no machines, CPR, or RSI. Finger sweep/Magill forceps unable to clear airway. Care about to be terminated when daughter arrives with valid paperwork verifying she is surrogate decision maker, demanding you intubate and recusitate the patient. Your medical director is well known for having a problem with intubated DNR patients. What do you do?
> 
> Scenario 2: You have just cleared a early-morning call at the end of your shift. It's 730, and you are enroute to the station to clear out for the day. Stopping at the McDonalds for some coffee, the manager approaches and tells you he has a customer who has vomited and asks if you would check them out. Begrudgingly, you do so. The patient is a 66 y/o male, vomitus evident, diaphoretic, ashen, and SOB. He is well-to-do and his wife is telling him to go to the hospital. He is telling her he won't go. After some convincing, he allows you to assess him, and discover he has audible PE with crackles and unstable vitals. 12 lead shows gross ST elevation in 3 leads, confirming AMI. Pt AOx3 and has refused transport to the point of getting angry. LEO called and will not arrest or detain the patient. Wife cannot persuade him. You and your unit tell him he will likely die if he does not go to the hospital, and he refuses. Contacting online med control, the physician tells you, "I don't care what you have to do, bring me that patient now." The patient insists that if you touch him, he will personally sue you and your partner. What do you do?
> 
> Scenario 3: 2am tones for Hospice patient in local nursing home with bowel cancer. Pt unconscious with irregular RR and unstable vitals, valid DNR. 10 family members and hospice representative present with patient. Nursing home demands you transport to the ER, as the facility has a policy forbidding patient death on premesis. Medical control also wants the patient transported to the ER with only pallative measures. Family is up in arms, stating the patient wished to die in his own bed. What do you do?



Scenario 1:
In most locations family members can nullify DNRs, especially proxies. The DNR doesnt exist if its ripped up.

Scenario 2:
Patient has mental capacity? Ask supervisor/med control for assistance on refusal documentation.

Scenario 3:
hospice with a policy forbidding death is an oxymoron...


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## JPINFV

NVRob said:


> 3)Transport. Patient is alive and OMD wants him transported, if the family doesn't have correct proof of surrogate decision maker they don't really have a say in the matter, its terrible to say but it's true. Politely explain to them why you are doing what your doing. If they are getting really rowdy get PD involved, you don't want to get hurt. This is a pretty awkward position to be in.



...yet the SNF RN is not a surrogate decision maker either. Why does the RN get to compel transport over the wishes of the family and hospice representative?


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## DesertMedic66

NVRob said:


> Some people will argue this though. He competently refused care prior to the event. We talked about this in class and I couldn't get a straight answer out of it. Lawyer said don't touch the pt unless it was a different crew who hadn't seen the pt prior to the collapse and medic instructor said unconscious pt means consent is implied.



My medic and I have waited on scene for someone to pass out before. Patient has severe SOB but refused transport. The son wanted his dad transported. We went back out to the rig to "finish paperwork". About 5 mins later the son runs out saying the dad passed out. And we loaded him up.


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## jjesusfreak01

These are easy:

1. Take em. If a family member has POA paperwork, then at some point either the patient or family decided to give it to them (which is beside the point because any family member can revoke a DNR). I also dislike the yellow DNRs in my state that only require a medical providers (MD, PA, NP) signature to be valid and have no place for family/patient signatures. I'll ignore those in two seconds if a family member requests because for all I know the nursing home's doc signed the DNR without any consent.

2. Leave em. Battery if you touch them. If you're inclined to do so (that is, don't have anywhere better to be), wait til he passes out or codes and then take him under implied consent. Even if the patient expressed a desire to not be transported, the family member can change that the second he passes out.

3. Take em, but this one is more difficult. A DNR is NOT a do not treat form. It does not give family authority to refuse transport, nor is it a request from the patient that you do not transport. If the patients family has POA paperwork at hand, then they can probably refuse the transport. If the patient is under hospice care at the nursing home, then the implication is going to be that they will die at the nursing home, and the ER is going to be extremely unhappy with you taking them there.

In my area, we have two resources that massively uncomplicate this issue. One is the MOST form, which indicates exactly what we can and cannot do (including transport to some degree). The other are dedicated hospice facilities. I have done transports via BLS ambulance to hospice homes with imminently terminal patients from their homes or from nursing homes. These facilities are equipped to offer complete palliative care that nursing homes cannot and will not provide.


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## Sasha

NVRob said:


> Some people will argue this though. He competently refused care prior to the event. We talked about this in class and I couldn't get a straight answer out of it. Lawyer said don't touch the pt unless it was a different crew who hadn't seen the pt prior to the collapse and medic instructor said unconscious pt means consent is implied.



At that point in time he refused care, but since then there was a change and his conditioned worsened. Reasonable people would assume that if he were able to talk for himself, with the recent "development" that he would change his mind, realize his life was actually in danger and not just a bunch of people trying to scare him into an expensive trip to the hospital, and consent to treatment.

At least that's what I'd assume! 

As for the RN not allowing the patient to die in their bed... It's kidnapping if the patient or POA says no, the nurse can't force him to go to the hospital. She can discharge him and then call the cops to have him removed... but she can't force you to take him to the hospital, and I wouldn't touch him. We have left patients in the hospital because they refused transport.

And for the first scenario... Sucks but the POA is the decision maker.


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## Melclin

*In regards to No.2*

I think pretty highly of my ability to negotiate with patients like this. I know the scenario assumes nothing has worked but I'd just keep chipping away at him until he came with us. See if we can negate the reasons he doesn't want to go. Play on their (usually considerable) respect for us, "We'll lose our jobs if you don't come to hospital. You seem like a pretty nice reasonable guy  You don't want us to lose our jobs now do you?". That one always works.


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## mycrofft

*Key word: "demand"*

In each case the "demander" ("demandor"?) was in the wrong.

By the way, the old "wait 'til they drop" deal actually doesn't apply IF a valid/informed/mentally competent DNR statement is uttered before losing consciousness. Otherwise, NO DNR is valid unless they die while oriented and alert, fighting you off to their last breath.

Following an illegal order is an illegal action.

Use logic and persuasion. Sticking around is OK, but not kidnapping someone because they lost consciousness.

PS: re patient "die in his own bed"...perhaps they meant home, not nursing "home"?


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## Cup of Joe

mycrofft said:


> By the way, the old "wait 'til they drop" deal actually doesn't apply IF a valid/informed/mentally competent DNR statement is uttered before losing consciousness. Otherwise, NO DNR is valid unless they die while oriented and alert, fighting you off to their last breath.



I believe that the wait till they drop works unless they have a DNR taped to their forehead (or in plain sight on by the patient) or if a family member is standing next to them and presents to you the patient's valid DNR that says you  cannot treat the patient.  Even then, a DNR doesn't say outright no treatment whatsoever, right?


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## MrBrown

Brown is going to ignore the first and last scenario, we have substantive medicolegal and systemic praxis differences than the US and commenting on them would not be appropriate.

The second bloke at McD's can stay where he is, if he doesn't want to come with us despite all efforts at negotiation then that is his choice.  He is a competent patient who has the right to decline our recommendation of treatment/transport, nothing will change that while he is competent and Brown strongly believes in patient choice regardless of situation.


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## mycrofft

*A verbal statement would suffice for DNR.*

If the pt is oriented and capable of an informed and rational statement, a verbal DNR is binding. If you told the EMT not to resuscitate you, then you woke up after two weeks in an ICU with both legs gone and on a ventilator, would you feel your right to security of your person had been violated.

Ignoring a verbal DNR statement due to absence of a witness would be like declaring any other battery to be legal if there was no witness.

Yeah, without a witness you can tell them there was no utterance, but you might wind up on the witness stand in a civil suit lying to a judge and jury. And maybe joined in there by all your co-workers, friends and family you might have said something to.


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## Ramathorn90

1) I would continue with full treatment as the DNR is now void on the count of the responsible party with valid paperwork stating she does not want the DNR/DNI to be respected.

2) Continue attempting to persuade Pt. by all possible means. Attempt acquiring consent to treat MONA/FONA. However, if Pt continues to remain AOx4, I'm not transporting. I'd like to be able to treat the next Pt who willingly consents for Tx. and transport in light of an MI and not be facing a judge for charges of kidnapping. 

3) Attempt to resolve issue between DON and family. If no responsible party (w/paperwork) near-by, then I will state to the family that they unfortunately do not have a choice in the matter.


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## JPINFV

...and yet no one has answered the question about where the RN gets to make unchallengeable and unilateral treatment choices without consent of the POA or family.


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## systemet

JPINFV said:


> ...and yet no one has answered the question about where the RN gets to make unchallengeable and unilateral treatment choices without consent of the POA or family.



Is this (3)?

Because that does sound a little tricky, and I guess it depends a little on the legal definition of a "DNR" in the given jurisdiction.  If a DNR only comes into effect at the point at which the patient's heart stops, then they get acute treatment / transport.  

It's hard, because you have medical control and the RN versus the patient's family, in a situation where arguably they're going to suffer, and it could be potentially litigious.  But there's a duty to care there.  So I think you have to transport.  It's in everyone's interest to try and smooth things out a little, and not get too confrontational.

Now if the DNR in this jurisdiction comes into effect at the point the patient loses consciousness, or it specifies no acute treatment / transport, and this is legal in the given region, then it's time to fight for what's right.  This means calling supervision / calling med control, and explaining that what they want you to do is illegal, and are they fully aware of the circumstances and consequences?  And trying to mediate between the family and RN.  If that doesn't work, you're in a bad place.  Refuse transport, and you may lose your job.  Transport and you victimise the patient and family, and will be criminally and civially liable.

That's the question really.  Is whether there's a document in place rendering it illegal to transport the patient.


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## JPINFV

systemet said:


> But there's a duty to care there.


The duty to follow the patient's wishes trumps all. Other wise we would be able to over rule an AMA for no better reason than, 'the patient is really really sick.' So the question now is, does hospice and the patient's family OR the nursing home represent the patient's wishes? Which actually brings up another question. If the hospice provider is an RN, why follow the SNF RN over the hospice RN? 

Besides, the SNF RN doesn't care about providing this patient care. The RN just doesn't want the patient to die under his or her care. That's not a valid medical reason to turf the patient. 



> So I think you have to transport.  It's in everyone's interest to try and smooth things out a little, and not get too confrontational.


So you don't mind getting confrontational with the family (who ultimately has to pay the bill for unwarranted and unwanted hospitalization)? 



> That's the question really.  Is whether there's a document in place rendering it illegal to transport the patient.


Actually, I don't see a document as being nearly as important as deciding who get's to ultimately decide medical care. The SNF RN, the hospice RN, or the family. In most, if not all states, there is already a legal order of precedence for who gets to make health care decisions in an unconscious patient who doesn't have a POA. If, say, the patient's spouse was part of the 10 family members present, I'd have a hard time over ruling their request in favor of an RN who's request basically boils down to "I don't want to deal with this patient any more."


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## mycrofft

*Definition of resuscitation*

Quote:
Originally Posted by JPINFV  
...and yet no one has answered the question about where the RN gets to make unchallengeable and unilateral treatment choices without consent of the POA or family. 

Is this (3)?

Because that does sound a little tricky, and I guess it depends a little on the legal definition of a "DNR" in the given jurisdiction. If a DNR only comes into effect at the point at which the patient's heart stops, then they get acute treatment / transport. 


Resuscitation is not just revival after clinical death, it actually begins with any lifesaving treatment to a diagnosed threat (e.g., oxygen to a decompensating asthmatic).

Having sat in a circle with family members and a convalescent center's manager with an apparently dying and somewhat disoriented father who had no living will or DNR established, I will say even if you are convinced of death's inevitability and proper place, it is very hard to decide to let someone die, whether or not they did have such wishes established, and part of that is worrying about how it will affect the others concerned. 

(BTW he snapped out of it, but that's another story)


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## firecoins

Situation 3 sounds impossible. Why would a SNF accept a hospice patient with a policy that no on dies at the facility?


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## systemet

JPINFV said:


> The duty to follow the patient's wishes trumps all.



I agree that it should.  I believe strongly in personal autonomy and freedom.  The question here is whether the patient has indeed expressed the wish that he doesn't want to be transported to acute care in an appropriate legal manner.

If the DNR is sufficiently detailed, and the laws in effect in the given jurisdiction allow a DNR to cover situations where the patient is incapacitated but not yet pulseless, then we're golden.  As I said, I wouldn't take the patient in that situation.

But if the DNR doesn't cover this situation, and the patient hasn't expressed their wishes in a legally acceptable manner, the situation becomes more difficult.  In this particular instance you have a sending facility and medical consult in agreement that the patient should be transported.  If he is incapacitated and in their care, deoending on the legal framework in place, they may get to make that call.




> Other wise we would be able to over rule an AMA for no better reason than, 'the patient is really really sick.' So the question now is, does hospice and the patient's family OR the nursing home represent the patient's wishes?



I agree that that's the primary issue here.  Where I've worked previously we use something called a "personal directive" to cover this situation.  It requires no physician input, no standardised form, just the signature of the patient and a witness, and allows the patient to describe exactly what procedures they are willing to allow in the event they lose decision-making ability, and gives them the option to nominate someone to make medical decisions in their place.  (In contrast, a POA delegates responsibility for financial matters)

A lot of the facilities have more detailed DNR forms that cover transportation, advanced care, analgesia / fluids / feeding etc.  But unfortunately at 0-dark-00 I've often been confronted with a random sheet of orders with "DNR" written in omnipotent red marker, with no explanatory notes, or incomplete forms.  I'm sure this isn't a unique experience. 




> Which actually brings up another question. If the hospice provider is an RN, why follow the SNF RN over the hospice RN?



When did a hospice RN become involved in the scenario?  The way I see it, is we have a sending facility calling for transport.  This may have been initiated by the RN, but has probably been done in consultation with an MD.  We have concerns about this, so for some reason we've chosen to contact med consult (presumably an EM Physician?), and they advise transport as well.

So we need a legal reason not to transport.  The family not wanting the patient to go is understandable.  But the questions remain, are they legally allowed to make decisions for the patient? And does the existing documentation prohibit transport?




> Besides, the SNF RN doesn't care about providing this patient care. The RN just doesn't want the patient to die under his or her care. That's not a valid medical reason to turf the patient.



Agreed, the stated reason is not medically valid.  However, the situation has been discussed with a physician (med consult), who seems to feel there is a medical necessity to transport the patient.  I don't think we get to overrule that.

The whole scenario of a nursing home that doesn't allow deaths on site is contrived and a little unbelievable.




> So you don't mind getting confrontational with the family (who ultimately has to pay the bill for unwarranted and unwanted hospitalization)?



I would *hate* to "get confrontational" with the family.  This would be a terrible situation to deal with.

I would try to mediate discussion between the nurse and family.  I would contact with a supervisor to diffuse responsibility a little.  I don't see the point in talking with medical consult, unless they represent a physician at the receiving facility, in which case it would be worth discussing with them the family's objections, and seeing if they change their mind.

Ultimately though, if there's a legal responsibility to take the patient to the hospital, it has to be done.  Hopefully it can be done with the consent of the family, but perhaps it can't.

The billing issue is crazy, by the way.  This wouldn't be billable to the family where I've worked, but I've never worked in the US.



> Actually, I don't see a document as being nearly as important as deciding who get's to ultimately decide medical care.



Well, I think the document plays a role in that decision, right?  I mean, we need to know the legal framework in place in the region where this event is occurring.  The documentation probably forms part of that.

For what it's worth, I have taken the personal risk of not beginning resuscitation in an out-of-hospital death where no DNR / personal directive etc. has been in place.  I did this with the realisation that if other members of the family who weren't present objected to this decision, it could cost me my licence, job, financial security, and possibly my freedom.  

But this decision isn't to be taken lightly.  And in this scenario we have multiple actors.  We've got med consult (again, not sure why), the sending facility and the family.  It would be best if we can somehow build a consensus so that everyone's happy.


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