Patient Autonomy Case Study

On the morning of May 17th, 2005, Nola Walker was involved in a two-car collision. Police and Ambulance were dispatched and arrive on scene at the intersection of Kenny and Fernley Street. Ambulance conducted various assessments on Ms. Walker which revealed no major injuries and normal vital signs. Mrs walker denied further medical investigation and denied hospital treatment. Later on, Queensland police conducted a roadside breath test that returned a positive reading, police then escorted Ms. Walker to the cairns police station. Ms. Walker was found to be unconscious, without a pulse and not breathing. An ambulance was called but attempts to revive her failed (Coroner’s Inquest, Walker 2007). The standard of Legal and ethical obligation appeared by paramedics required for this situation are flawed and require further examination to conclude whether commitments of autonomy, beneficence, non-maleficence and justice were accomplished.

Autonomy is a concept found in moral, political, and bioethical reasoning. Inside these connections, it is the limit of a sound individual to make an educated, unpressured decision. Patient autonomy can conflict with clinician autonomy and, in such a clash of values, it is not obvious which should prevail. (Lantos, Matlock & Wendler, 2011). In order to gain informed consent, a patient

must be free from external pressures, have the capacity to make a choice, and understand the consequences relating to each option given (Townsend & Luck, 2013). After paramedic’s initial observation and assessments, Ms. Walker was given the option for further medical investigation at a hospital, which she denied as she claimed she was not hurt and did not require and help (Coroner’s Inquest, Walker, 2007). It is important that the concepts of consent and refusal are understood and correctly applied by paramedics, as it can result in legal ramifications if they are breached. (Steer, 2007).

The medical treatment Act 1988 (Vic) makes provision for the competent adult to refuse medical treatment, even if that refusal may place their life at risk (Steer, 2007). A treating paramedic described Ms. Walker as being “…lucid and able to converse with her in a meaningful way.” (Coroner’s Inquest, Walker, 2007). Due to the outcome of the initial assessments, the treating paramedics deemed Ms. Walkers refusal to go to a hospital was valid. After paramedics left the scene a breath alcohol test was conducted by police that found a reading of 0.194% (Coroner’s Inquest, Walker, 2007). As this reading was conducted after paramedics had left the scene they cannot be accountable for the misjudgement of her consent. If known earlier, paramedics may be accused of negligence. While on scene paramedics failed to perform an appropriate head to toe trauma assessment as required by QAS Clinical Practice Procedure’s [CPP’s] (QAS CPP). Paramedics examined Ms. Walkers shoulder and rib area but did not auscultate her chest or examine her abdomen appropriately (Coroner’s Inquest, Walker, 2007). If performed correctly, Ms. Walkers injuries may have been detected and appropriate treatment performed, the failure to so may result in legal ramifications.
Beneficence is characterized as a demonstration of philanthropy, leniency, and thoughtfulness with a solid implication of doing great to others, including moral commitment. All paramedics have a good key commitment to doing great. With regards to a patient relationship, the paramedic is committed to, dependable and no matter what, advance the welfare and enthusiasm of the patient. In medicine services, philanthropy is one of the moral establishments (Caldwell et.al, 2014). A necessary piece of work as an expert is the fundamental morals of beneficence. After completing two vital signs assessments and noting abrasions possibly caused by seat belt trauma (Coroner’s Inquest, Walker, 2007), attending paramedics believed it would benefit Ms. Walker to be transported and undergo further assessments in a hospital as it was believed there may be hidden complications, one of the paramedic made this clear on multiple occasions. Ms. Walker was quite set on refusing further medical intervention (Coroner’s Inquest, Walker, 2007). As Ms. Walker was deemed to have minimal physical trauma after assessment and denied further hospital treatment attending paramedics believed their obligation was fulfilled in regards to beneficence.

Non-maleficence signifies "do no harm". Healthcare practitioners should refrain from giving insufficient treatment or acting with the perniciousness toward patients. This guideline, be that as it may, gives minimal helpful direction. The applicable ethical inquiry is whether the advantages exceed the weights (REINISCH, 2013). The reason for this inquest is due to undetected injuries sustained from the motor vehicle accident that caused the death of Ms. Walker, this could suggest paramedics did not fulfil their obligation to do no harm. QAS clinical practice procedure (2015) identifies that particularly in trauma cases the “head-to-toe” is necessary to establish a comprehensive assessment of patient status. Finding of the inquest revealed internal haemorrhage and severe chest injury was present, therefore, it can be assumed paramedics did not perform adequate assessments. Although the risk of complications was identified by paramedics, police were told “Ms. Walker was fine.” (Coroner’s Inquest, Walker, 2007). Assuming Ms. Walkers potential risk was communicated her injuries may have been addressed earlier. Poor communication between paramedics and police could be seen as a fault for the paramedic’s duty of non-maleficence.

It is held at common law that each individual has the right to be self-governing and the legal duty to act fiduciarily does not negate patient autonomy. Based on the finding of the inquest we can conclude that the patient was treated with dignity and respect, the paramedics on scene outlined their concerns whilst the patient had the right to refusal. Justice was shown when paramedics outlined the patient’s options regarding the refusal of treatment.
When examining evidence present in the inquest we can determine that the paramedics acted to withhold patient autonomy, beneficence, non-maleficence and justice.

Paramedics deemed the patient competent and therefore Ms. Walker had the right to refuse treatment, which held paramedics legally and ethically bound to her decisions. Although negligent actions were identified which may have resulted in a substandard patient treatment, paramedics acted with intent to better the patient despite unforeseen future factors. There is no set structure paramedics can follow in an ethical and legal standpoint thus paramedics must tailor them to every given

situation.

References
Caldwell, C., Floyd, L., Taylor, J., & Woodard, B. (2014). Beneficence as a source of competitive advantage. Journal of Management Development, 33(10), 1057-1079.
Lantos, J., Matlock, A., & Wendler, D. (2011). Clinician integrity and limits to patient autonomy. Journal of the American Medical Association, 305(5), 495-499.
Office of The State Coroner. (2007). Inquest into the death of Nola Jean Walker. Queensland Courts, file number 1211/05(6).
Queensland Ambulance Service. (2011). Clinical Practice Guidelines: Assessment. Available from http://www.ambulance.qld.gov.au/clinical.html
REINISCH, C. (2013). Ethical Guidelines Particular to Practice. Ethical and Legal Issues for Doctoral Nursing Students: A Textbook for Students and Reference for Nurse Leaders, 79.
Steer, B. (2007). Paramedics, consent and refusal – are we competent? JESPHC, 5(1), 1-10
Townsend, R., & Luck, M. (2013). Applied Paramedic Law and Ethics Australia and New Zealand. Chatswood, NSW: Churchill Livingstone Australia.