The Ethical Implications and Impact of Pre-hospital Intubation on Paramedic Profession - Literature review Example

The Ethical Implications and Impact of Pre-hospital Intubation on UK Paramedic Profession Total Number of Words: 1,739 Table of Contents I. Introduction ……………………………………………………………….. 3 II. Compare and Contrast Utilitarian from Deontological Theories ……. 4 III. Impact of JRCALC’s Recommendation over the Role of UK Paramedics within the Healthcare System ……………………….. 6 IV. Conclusion ………………………………………………………………… 8 References …………………………………………………………………… 10 – 13 Introduction Each time a patient needs mechanical ventilation, the use of intubation has been considered the standard treatment procedure by UK paramedics (Deakin et al., 2008). However, the Joint Royal Colleges Ambulance Liaison Committee (JRCALC) has recently recommended that intubation should no longer be considered the ‘gold standard’ for airway management since the health consequences of using intubation is greater than its health benefits (Joint Recommendation from AETAG/JRCALC Airway Group, 2008). Since intubation technique is invasive by nature (Davis, 2008; Waltl et al., 2001; Asai, Wagle, & Stacey, 1999), UK paramedics should focus more on the use of supraglottic airway devices (SADs) like oesophagotracheal combitube (ETC), laryngeal tube (LT), and other kinds of laryngeal masks such as the laryngeal mask airway (LMA) among others – a non-invasive procedure (Berlac et al., 2008). This study will focus on discussing the ethical principles concerning the impact of JRCALC recommendation on UK paramedic practice. As part of discussing the ethical implications and impact of pre-hospital intubation on UK paramedic profession, utilitarian and deontological theories will first be compared and contrast. Eventually, the impact of JRCALC’s recommendation over the role of UK paramedics in terms of professional issues, autonomous practice and morale will be thoroughly discussed. As part of the conclusion, a brief recommended solution to prevent demoralizing and disqualifying the role of UK paramedics in terms of attending to emergency cases will be provided. Compare and Contrast Utilitarian from Deontological Theories Deontological and utilitarian ethical theories are similar in the sense that both approaches are used in deciding whether an action is morally acceptable or not. Deontological theories are commonly based the intrinsic character of an action or a universally accepted actions rather than the end result of the action (Isenberg, 1964) whereas utilitarianism is basically a form of ‘consequentialism’ which means that moral actions made by the paramedics should be based on the consequences of their own actions (Thomas, 1998). Upon analyzing the definition of deontology and utilitarianism, the concept of deontology is totally different from the theory of utilitarianism in the sense that deontology remains focus on judging an action by purely observing the righteousness or wrongness of an action regardless of whether the end result of the action is good or bad (Nishukan, 2007). Similar with the theory that was proposed by Immanuel Kant, deontology judges moral issues by carefully examining the type of actions being committed by a person instead of taking into consideration the consequences of an action (Kay, 1997). In relation to the theory of deontology, the idea that UK paramedics insert tracheal intubation to patients who need mechanical ventilation during emergency response is ethically acceptable. Since the theory of deontology is a ‘duty-based ethics’ (Kay, 1997), UK paramedics are obliged to perform tracheal intubation during emergency situation regardless of whether or not they are professionally capable of performing such as sensitive medical task. Considering the fact that only a few number of patients receive intubation each year, most of the UK paramedics who are assigned to respond on emergency cases do not have the professional competency and adequate experience to perform the actual tracheal intubation during emergency cases (Blacke, 2007). Since there are possible negative health consequences associated with the provision of esophageal intubation (Eddleston et al. 2006; Metersky, 2005), utilitarian theory does not accept giving UK paramedics the privilege to perform tracheal intubation on patients. Hunter (2006) explained that intubated patients are at risk of developing nosocomial bacterial pneumonia two days after using the mechanical ventilation. In line with this matter, several studies show that nosocomial bacterial pneumonia is a common factor that increases the mortality rate of intubated patients (Bercault & Boulain, 2001; Heyland et al., 1999). Several studies also revealed that intubated patients are at risk of developing other hospital-acquired diseases like the methicillin-resistant Staphylococcus aureus (MRSA) (Philips et al., 2005; Ogata et al., 2004; Takahashi et al., 2003), psudomonas aeruginosa (Favre-Bonté et al., 2007; Yanagihara et al., 2000), haemophilus influenza (Yanagihara et al., 2000), fungi, viruses, and other species like proteus,serratia, and klebsiella (Guidelines for the Management of Adults with Hospital-acquired, Ventilator-associated, and Healthcare-associated Pneumonia, 2005). Aside from worsening the health condition of patients who need to undergo the process of intubation technique, the fact that intubated patients could end up developing pneunomia and other hospital-acquired diseases associated with the use of intubaton and ventilator requires the patients to stay at least 10.13 days longer at the intensive care unit (ICU). (Olaechea et al., 2003; Kappstein et al., 1992) Over staying at the ICU would mean a signiticantly increase on the patients’ hospital bill. Impact of JRCALC’s Recommendation over the Role of UK Paramedics within the Healthcare System It is good to promote health and life-saving benefits of using SADs over the traditional endotracheal intubation technique. However, JRCALC’s recommendation that the use of SADs should be considered as the ‘gold standard’ for airways instead of the traditional endotracheal intubation technique can negatively affect the role and credibility of UK paramedics in terms of their profession, autonomous practice, and morale (Davis, 2008; Deakin et al., 2008). As part of presenting some valid evidences with regards to the need to consider the use of SADs as the ‘gold standard’ for airway management, JRCALC Airway Working Group revealed that the existing paramedic training is not enough to effectively train the UK paramedics to deliver a safe pre-hospital intubation (Deakin et al., 2008). Under the paramedics’ training requirement over the use of endotracheal intubation, trainees are required to perform at least 25 intubations as part of their hospital training (Deakin et al., 2008; Lawler et al., 1991). However, completing this requirement is not enough to ensure that each trainee has sufficient knowledge and skills to perform an actual endotracheal intubation during emergency situations (Kestin, 1995; Lawler et al., 1991). Trainees should perform close to 60 endotracheal intubations to reach at most 90% success rate. (Konrad et al., 1998) Since newly trained UK paramedics has officially completed only 25 intubations from their hospital training, these professionals are less likely to be able to provide successful intubation. In general, the use of endotracheal intubation technique is very difficult to perform as compared with SADs. Therefore, improving the paramedics’ training on intubation is not be a good option when it comes to ensuring the health and safety of the patients. The paramedics’ success rate on intubating the patients who needs mechanical ventilation is not dependent on the length of service of each paramedic but on their personal experience in performing the endotracheal intubation method (Garza et al., 2003). Therefore, allowing the general public to learn about the incompetency of some the paramedics to perform sensitive medical procedures associated with the use of endotracheal intubation will automatically discredit most of the UK paramedics to perform the necessary airway management using intubation technique (even if some of the members of the UK paramedics have the expertise on intubation). Since there are patients who received pre-hospital intubation died either during or after being discharged from the local hospitals, there is a strong possibility for some people to think that the presence of the UK paramedics has something to do with the deaths of their love ones. In worst case scenario, millions of local people might lose trust on the professional qualifications of the paramedics. This will eventually lower the dignity and morale of the ambulance workers. Pertaining to the existing system and future training and educational development of UK ambulance trust, a research study revealed that the UK ambulance service is still in the process of going through a transition stage (Cooper, 2005). It means that there is a long way to perfect the emergency practice of the paramedics throughout the Untied Kingdom. Since the use of SADs also depends on the ability of the paramedics to effectively use these airway devices, publicly announcing only the disadvantages of using the endotracheal intubation over the use of SADs will only hurt the morale of UK paramedics in terms of their professional qualifications, autonomous practice, and morale. Conclusion Deontology is all about the rightness or wrongness of a chosen action depending on the moral significance of the action (Audi, 1999). Since the main reason why UK paramedics perform intubation is to perform their duty in terms of saving the lives of endangered people during emergency cases, the act of performing the intubation procedure is considered as an acceptable action. It simply means that the ethical principles of deontology is more focused on the good intensions of the UK paramedics rather than the health improvements of the patients. Instead of using the theory of deontology as a way to measure the ethical implication of JRCALC’s idea over the UK paramedic profession, it is better to use the utilitarian theory when coming up with a moral and ethical conclusion about the entire situation. Even though JRCALC’s recommendation that intubation should no longer be considered the ‘gold standard’ for airway management could somehow negatively affects the credibility of the UK paramedic profession, it is fair to conclude that JRCALC’s recent recommendation that intubation should no longer be considered the ‘gold standard’ for airway management is simply the right thing to do. Basically, UK paramedics must must not act on pure motive alone. Instead, this group of professionals should consider not only their good intensions but also the probable and actual outcome of their actions when providing temporary care and treatment to the patients. For instance: Rather than promoting the practice of pre-hospital intubation, UK paramedics should promote the use of other non-invasive methods which could enable the paramedics and other health care professionals perform respiratory intervention during emergency cases without causing any forms of physical harm to the patients. In the end, there will be a lesser chance for UK paramedics to increase the patient’s risks of suffering from hypoxemia, hypercapnia, and/or untimely death aside from other complications like bradycardia, laryngospasm, bronchospasm, and apnea which is possible with the use of tracheal intubation (Kabrhel et al., 2007). To avoid disqualifying and making the UK paramedics accountable for the death of patients who received pre-hospital intubation, UK ambulance trust should categorize the use of intubation as a specialized airway management procedure. By allowing only individuals who are professionally qualified and capable of performing endotracheal intubation technique, there is a higher possibility that the number of pre-hospital intubation failures would decrease over time without endangering the qualifications of the UK paramedics when delivering pre-hospital health care services to patients. *** End *** References: Asai, T., Wagle, A., & Stacey, M. (1999). 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