ETHICS Part I by MNNn61


      Part I

    June 5, 2003
Moritz Haager PGY-2
 Dr. Carol Holmen
            Ethics vs.. Law
“..ethics and law are not equivalent.
   Adherence to the law does not result in
   ethical behaviour, and ethical behaviour
   may not be covered by the law or may in
   fact be contrary to law or policy….ethical
   duties typically exceed legal duties, and in
   some cases, the law mandates unethical
          • Derse. Emerg Med Clin North Am. 1999; 17(2): 307-
               Ethics vs. Law
 Law
     A formal expression of a social ethical
      consensus that sets a minimal standard of
     Does not cover large areas of conduct
 Ethics
     Branch of philosophy dealing with human
      conduct which acts as a moral repository of
      societal norms
     Less formal but more pervasive than law
    What is unique about ED ethics?
   Most literature and discussion focused on non-
    acute setting
   Pts present w/ rapid change in health
   Little continuity of care / familiarity w/ pt
   Lack of reliable information
   Need to make rapid potential life or death
    decisions w/ limited information
   Pts often not in ED of their own volition
   Pts often impaired, noncompliant, or hostile
  What is an Ethical Dilemma?
 Decidingwhich of 2 or more choices
 provides the greater overall good
     Autonomy vs. justice
     Confidentiality vs. public duty
     Beneficience vs. non-maleficience
     etc
              Ethical Models


    Deontologic Theory               Consequentialist Theory

Relies on ‘fundamental’ rules    Based on predicted outcomes
    e.g. first, do no harm        e.g. do more good than bad
 Fundamental Ethical Principles
 1.   Preservation of Life
      Beneficience
      Non-maleficience
 2. Respect Autonomy
 3. Justice
 4. Truthfulness
           Preservation of Life
 Beneficience
     Acting in the pts benefit (= doing “good”)
     Alleviation of suffering
 Nonmaleficience
     Primum non nocere (first do no harm)
 From  Greek for ‘self-rule’ = Patient right to
 Respecting vs.. creating autonomy
     Respecting = following pts wishes
     Creating = allowing pt to make a choice e.g.
      informed consent
 Autonomy  vs. paternalism
 Benign paternalism
     Making therapeutic decisions for incompetent
      pts in good faith
 Complex   concept E.g. resource allocation
 3 major types:
     Egalitarian
       • equal access for all
     Libertarian
       • social or economic ability should be allowed to
         determine access
     Utilitarian
       • combines features of above to maximize public
         utility (Canadian System)
                 Case 1
A   83 you Punjabi male is brought to the
  ED for ‘constipation’. He looks cachexic
  and dehydrated but is oriented and able to
 Physical exam reveals an enormous hard
  irregular mass in the abdomen which is
  almost certainly cancerous.
                    Case 1
 You call the radiologist to arrange an abdominal
  CT. You don’t realize the son is standing behind
  you as you relate your suspicion about the
 After you hang up the son approaches you and
  asks you not to tell his father the Dx because he is
  very afraid of death and would not want to know. In
  India the word Cancer is like a death sentence he
  tells you. He feels that telling him would destroy his
  fathers quality of life.
   Trust b/w pt and physician
   Is truth always best? Straightforward?
       Cultural differences
       Impact of disease
       Gradual vs.. immediate disclosure
   Therapeutic privilege
       Concept that a physician may withhold information if
        doing so would result in harm to the pt (non-
       Becoming a historical concept
   Withholding information, at least temporarily, may
    be justified, BUT only if there are compelling &
    defensible reasons
          McMaster Decision Model
1.       List the alternative courses of action
2.       Assess each alternative in 3 spheres:
          Medical
          Patient
          Legal
3.       Apply relevant ethical principles to each
4.       Justify each choice as a moral statement
5.       Formulate a conclusion
                   Iserson Model
1.        Have you already dealt w/ a similar
          problem? Do you have a rule for it?
2.        Is there a safe time-buying option?
3.        If immediate decisions needed:
     1.     Impartiality test – would you want this done
            to you?
     2.     Universality test – would you want this
            done in all similar situations?
     3.     Interpersonal Justifiability test – can you
            strongly justify your actions to others?
                Case 2
 You are taking care of a 25 yo female
 suffering from acute traumatic C1 on 2
 dislocation with complete cord transection.
 She is ventilator-dependant and a
 complete quadriplegic with no chance of
 recovery. She is alert enough to answer
 questions through eye opening and
                 Case 2
 Her husband indicates to you that they
 wish for the ventilator to be turned off.
 They had discussed this hypothetical
 situation in the past as the family knows
 Christopher Reeves who used to ride
 horses at their ranch She confirms this
 when you ask her if this is true.
 The  pts right to agree to, OR refuse a
  medical treatment (autonomy)
 Requires physicians to inform pts about
  the potential consequences of both
  accepting and refusing a treatment
   Implied vs.. Explicit Consent
 Implied    Consent
     Pts actions in keeping w/ agreeing to Tx
     E.g. Pt rolls onto side and pulls down pants
      when told of need to perform a DRE
 Explicit   Consent
     Verbal or written, and documented on chart
     More involved discussion of risks, benefits, and
     Should be obtained by person doing procedure
       Components of Consent
1.   Possession of decision-making capacity
2.   Provision of pertinent information about
     the proposed therapy on which to base a
3.   Consent is voluntary, and obtained w/o
     coercion or manipulation.
Guidelines for informed consent
    Discuss procedure including anticipated
     impact, significant risks, and alternatives
    Encourage questions
    Explain likely outcome if treatment is not
     provided without resorting to coercion
    Specifically address individual concerns
    Adhere to above for all patients even if
     they seem prepared to accept any
           Assault vs.. Battery
 Assault
     Threatening to touch someone
 Battery
     Touching someone without that persons
     Any intervention in the ED provided w/o the
      pts consent in situations other than those
      where consent is not required
Exceptions to Need for Consent
 Based     on concept of beneficience
     Emergencies: If immediate threat to life or
      limb, and unable to give consent
       • Unconscious trauma victim
     Person lacking capacity and at acute risk
       • Intoxicated drug OD pt wanting to leave
       • May require invocation of Mental Health Act
     Treatment of minors
       • 12 yo Jehovah's witness w/ acute blood loss
     Public Health Regulations
       • Mandatory reporting laws
                   Age of Consent
   No age of consent in Canadian tort law
   Provincial legislation for age of consent:
       PEI
         • 18 yo or married (for surgery)
       NB
         • 16 yo or younger if ‘competent’
       PQ
         • 14 yo
       SK
         • 18 yo or married (for surgery)
       BC
         • 16 yo if unable to obtain parental consent; need 2nd physician
           to provide written opinion of necessity of Tx
                      Case 3
   14 yo female is brought in by her mother. A
    friend of the girl has just phoned the mother to
    say that she had gotten drunk, done drugs, and
    then had sex with a nineteen year old. The pt
    denies all this. Mom demands a drug screen
    AND pelvic examination. She firmly states that
    as the pt is a minor, and she the parent, you
    must abide by her wishes. Do you? What if the
    girl refuses the blood and urine tests, and pelvic
    exam? Are you obliged to refer her to the sexual
    assault team? Are you obliged to notify the
                 Case 4
A  12 yo girl is brought to the ED by her
 mother c/o fever & dysuria. The pt does
 not want her mom present during the
 interview or exam. She is pre-menarchal,
 and denies being sexually active, or
 sexual or physical contact against her will.
 Her temp is 38.0. Superficial genital exam
 reveals multiple labial ulcerations and
 malodorous vaginal discharge.
                Case 5
A 16 yo female is brought to the ED by her
 mother for abd pain, vomiting, and PV
 bleeding. You examine her in private. She
 admits to consensual sexual activity. A
 urine pregnancy test is +ve, and she has a
 tender R adnexal mass. U/S confirms a
 ectopic pregnancy. She understands the
 need for intervention and is willing to see
 O & G but insists you not tell her mom.
                    Case 6
 A 70 yo man with gangrene of R foot + leg from
  a diabetic ulcer is in your ED. He is requesting a
  Rx for abx & painkillers. You tell him that you
  think he should come into hospital and see a
  surgeon. He refuses this saying he does not
  want his leg amputated. “better to die than lose
  your independence” he tells you.
 His daughter is present and argues with him
  vehemently. At one point she tells him “you can’t
  go on like this, all cooped up by yourself in that
  house not taking care of yourself”. She tells you
  he has been depressed since his wife’s death 2
  yrs ago.
   = Ability to comprehend & process:
       Information about the treatment or test
       Potential consequences of acceptance or refusal
   Capacity can fluctuate with situation & time
       Assess on sliding-scale: the more serious the decision,
        the more competent the pt should be
 Age does not necessarily preclude capacity
 Assessment of capacity poorly studied & subject
  to bias
 Few statutory laws other than those regarding
  formal admissions for psychiatric pts to guide you
            Impaired Capacity
 Examples     of impaired capacity
     Intoxication
     Organic brain disease (e.g. Alzheimer’s)
     Minors
     Suicidal pts
     Other psychiatric illnesses
Aid to Capacity Evaluation (ACE)
 Tool for systematic evaluation of capacity
  developed at U of T by experts in law,
  ethics, and medicine
 Scores 7 areas as ‘yes, no, or unsure’
 Requires identifying & addressing any
  communication barriers
 Done in conjunction w/ discussing risks,
  benefits, & alternatives of proposed Tx
 ACE questionnaire available at
               ACE Questions
 Ability   to understand:
      Current medical problem
      Proposed Tx
      Alternative therapies (if any)
      Option of refusing any Tx
      Reasonably foreseeable consequences of
       accepting proposed Tx
      Reasonably foreseeable consequences of
       refusing proposed Tx
 Is   the person’s decision influenced by:
      Depression
      Delusions or psychosis
             ACE Conclusions
 Finalassessment subjective, but based on
  score in prior areas
     Pt should demonstrate ability to understand
      relevant info AND possible consequences
 Clinician   designates pt as one of:
     Definitely capable
     Probably capable
     Probably incapable
     Definitely incapable
            Validity of ACE
 Cross-sectional study of 100 inpatients w/
  questionable capacity facing serious
  medical decisions
 Assessed by residents & research nurse
  using ACE + MMSE, general impression
  of attending physician, and formal
  assessments 2 separate experts
 Compared results of each
                  Validity of ACE
   Results
       ACE took ~15 min to administer
       Agreement b/w ACE and expert opinion was sig
        higher (k = 0.90-95) than the general impression of
        attending physician (k = 0.86)
       MMSE scores of 0-16 correlated sig w/ incapacity (k =
       A MMSE score of 0-16 combined w/ an ACE score of
        probably or definitely incapable resulted in post-test
        prob of 96% for incapacity
       A MMSE score of >24 combined w/ an ACE score of
        probably or definitely capable resulted in post-test
        prob of incapacity of 3%
              Validity of ACE
 Conclusions
     ACE & MMSE both agree well w/ expert
     Indeterminate results (probably capable or
      incapable; MMSE score 17 – 23) correlate
      more poorly and should prompt alternative
     Combining ACE and MMSE preferable
            • Etchells et al. J Gen Intern Med. 1999; 14: 27-34
                Case 7
 Anill-appearing 2-year-old with a fever
 and stiff neck appears to have meningitis.
 His parents refuse a lumbar puncture on
 the grounds that they have heard spinal
 taps are extremely dangerous and painful.
 They refuse treatment and investigation,
 saying, " We'd prefer to take him home
 and have our minister pray over him."
                Case 8
A 5-year-old child has just had his second
 generalized tonic-clonic seizure in a 4
 month period. You have recommended
 starting an anticonvulsant. The parents
 have concerns about the recommended
 medication and would prefer to wait and
 see if their son has more seizures. How
 should you respond to the parents
         Treatment Refusal
A  person of proper mental capacity has
  the right to refuse even life-saving Tx
 A parent or guardian may NOT make this
  same decision for a minor in their charge
 Written documentation corroborated by
  family members have been deemed
  sufficient grounds to withhold emergent
  therapy in an unconscious patient
                Treatment Refusal
 The key question in the ED regarding refusal of
  treatment is whether the patient is competent to
  make this decision
 Difficult area, but generally based on:
       Set of values and goals
       Consistency in decision-making
       Ability to understand & communicate info
       Linguistic & conceptual skills
       Sufficient life experience
       Ability to reason
   Refusal of life-saving measures usually mandates
    assistance in determination of competency
                  Case 9
A  50 yo male receiving palliative care for
  metastatic stomach CA is brought in by his
  family b/c of poor pain control and inability
  to tolerate PO feeds
 His vitals are 37.4 / 110 / 96/70
 He looks cachectic, jaundiced, dry, is
  drowsy & unable to answer Q’s or
  cooperate with exam
 He has multiple metabolic abnormalities
  including renal failure on his lab work
                   Case 9
 His  wife states that he did not wish for life-
  prolonging measures or resuscitation, only
  for “comfort and dignity”
 His wife does not want you to start an IV,
  however his son & daughter argue that he
  is dehydrated and should not starve to
 How do you approach this?
                 Case 10
A   79 yo male is brought to the ED from a
  nursing home in acute resp distress.
 Recent admission records indicate COPD,
  end-stage RF, and dementia. He is non-
 On exam he is in sig resp distress. His
  vitals are 38.0 / 130 / 140/90 / 30 / 79% on
  40% O2
 He is frail and unable to answer Q’s.
                Case 10
 There  is no documented code status
 The only family member you can reach is
  a son who lives in Miami. He last saw his
  father 8 mo ago. The son informs you that
  his father would not want any aggressive
   Substitute Decision Makers
 Person  chosen to make medical decisions
  on behalf of an incompetent pt
 Role is to use “Substituted Judgment” to
  try and mirror what the pts wishes most
  likely would be
       Substitute Decision Maker
 Murky     area in Canadian law:
      family members probably not legally
       empowered to act as substitute decision
       makers unless specifically court appointed,
       although this is common practice
 If   no appointed SDM, use in rank order:
      Court-appointed guardian  spouse / partner
        child  parent  sibling  other relative
 If   no one available need public guardian
 “Mature   Minor”
     Minor capable of understanding the risks &
      benefits of a Tx are entitled to make
      autonomous decisions
 “Emancipated     Minors”
     Sub-group of mature minors
     Those who support themselves independently
      and live separately from their parents, are
      married, and / or serve in the armed forces.
A  45 yo male is brought in by EMS for
  polydrug OD. He is intubated and placed
  on a ventilator for resp failure.
 A suicide note is found on scene in which
  the pt claims he has the right to choose to
  die on his own terms given his Dx of ALS,
  that he is rational and not depressed, and
  that he will sue anyone resuscitating him.
 His   common-law wife arrives with his
  ‘living will’. It was formulated 6 mo prior,
  witnessed and notarized. In it the pt clearly
  states that if he is “ a condition that is
  terminal with no reasonable hope of
  recovery I do not want heroic measures to
  prolong my dying..”
 His wife states he would not want these
  interventions and demands you turn the
  ventilator off
                      Case 11
   An elderly man with end-stage emphysema
    presents to the emergency room awake and alert
    and complaining of shortness of breath. An
    evaluation reveals that he has pneumonia. His
    condition deteriorates in the emergency room and
    he has impending respiratory failure, though he
    remains awake and alert. A copy of a signed and
    witnessed living will is in his chart stipulates that
    he wants no "invasive" medical procedures that
    would "serve only to prolong my death." No
    surrogate decision maker is available. Should
    mechanical ventilation be instituted? What if he
    presents confused and somnolent?
          Advance Directive
 Legal document outlining a pts wishes
  regarding their medical Tx in the event of
  becoming incapable of directing their care
 May assign a person to be SDM in which
  case it is a “proxy directive” or “durable
  power of attorney”
 Can be revoked by the pt at any time
                Case 12
A   16 yo female presents w/ PV bleeding
  and abd pain. She came alone.
 By Hx & exam she is 10 wks pregnant and
  is having an incomplete abortion with sig
 You discuss the situation with the pt and
  after discussing the options she states she
  wants a D & C
               Case 12
 As you hang up the phone after talking to
 O & G the mother identifies herself to you
 and asks what is going on with her
 daughter. You ask her to speak with the
 pt. She returns stating her daughter has
 no idea what is going on and as the parent
 she demands to know what is wrong.
                Case 13
A 24 yo male presents w/ penile d/c. He
 admits to using the services of a prostitute
 on a recent business trip to Thailand. You
 feel he likely has gonorrhoea and Tx him
 accordingly. His wife is in the waiting
 room. He demands you keep his Dx
 confidential stating that it was a “one time
 thing” and if she knew it would ruin their
 marriage. You buy yourself some time by
 going to grab a prescription padOutside
 you are approached by his wife who asks
 what is the matter with her husband.
                Case 14
A  60-year-old man has a heart attack and
 is admitted to the medical floor with a very
 poor prognosis. He asks that you not
 share any of his medical information with
 his wife as he does not think she will be
 able to take it. His wife catches you in the
 hall and asks about her husband's
 prognosis. Would you tell his wife?
    has the right to hold the physician to
 Pts
 secrecy regarding personal info
EXCEPT where:
     Doing so contravenes legal obligations
     Doing so may result in harm to others
     Doing so may result in harm to the pt AND the
      pt is incompetent
 All reasonable steps must be taken to
  inform pt of intended breach of
                Case 15
A   55 yo female is brought to the ED for
 decreased colostomy output and abdominal
 pain. She has a Hx of TAH & BSO for
 ovarian CA 5 yrs ago. She looks mildly
 unwell and has generalized abdominal
 tenderness, but is otherwise stable. An U/S
 shows peritoneal carcinomatosis. Your staff
 surgeon who has not seen the pt, shrugs
 and tells you to send her back to the
 peripheral hospital from where she came.
 When you ask him about what you should
 tell her he says “Nothing. Let the GP handle
                Case 16
 You  are about to go see your next pt who
  is here after a minor MVA when you are
  intercepted by her daughter in the hall
 She tells you that her mother has cancer,
  but she has not told her of this and asks
  you to keep this secret.
 On exam there is an obvious mass lesion
  on the left breast. As you are auscultating
  the pt asks you about the mass.
                Case 17
A  89 yo male is brought to the ED for
  cough & resp distress.
 You find he has b/l pneumonia, chronic
  pulmonary edema, as well as a UTI
 He was discharged 3 wks ago for CHF
  exacerbation with multiple complications
 He was a full code status at that time
                Case 17
 Despite treating him with Abx, diuretics,
  and O2 his breathing continues to
  deteriorate. He starts to look more septic
  so you start him on biPAP and dopamine.
 You discuss the situation w/ his wife.
  When you bring up code status she
  becomes upset and insists everything be
 Just then you are called into the resus
  room – your pt is in PEA
                     Case 18
   A 45 yo female of is brought to the ED w/ fever +
    cough. She is in a persistent vegetative state x 2
    yrs following an MVA, lives in a nursing home
    and depends on a G-tube for nutrition. She is
    tachypneic and her O2 sats are 86% on RA. You
    Dx her w/ pneumonia and start her on abx and
    O2. As she looks unwell you broach the topic of
    code status. The family, who are Orthodox Jews,
    insist that she receive all measures including
    intubation & ICU care if necessary. Is this
                Medical Futility
 Futility
      action that is ineffective or w/o useful purpose
 Medical     futility
      Variety of definitions but none widely
      based on largely subjective opinions as we
       often don’t really know the true efficacy of a
       treatment, nor can predict its success in a
       particular patient
             Medical Futility
 AHA ACLS guidelines for terminating
    BLS & ALS have been attempted appropriately
     w/o ROSC or breathing
    Deteriorating pt condition despite maximal
     therapy precludes likelihood of recovery (e.g.
     septic shock in ICU)
    Disease states from which no successful
     resuscitation has been reported in well-
     designed studies (e.g. metastatic CA)
               Medical Futility
 Schneidermann       et al 1990
     A treatment is futile if “…merely preserves
      permanent unconsciousness or …fails to end
      total dependence of intensive medical care”
     Efforts can be terminated, or care withdrawn
      w/o pt approval “..when physicians conclude
      (either through personal experience,
      experiences shared with colleagues, or
      consideration of empiric data) that in the last
      100 cases, a medical treatment has been
                Medical Futility
 Brody    and Halevy 1995
     Physiologic futility
       • failure to produce a physiologic response
     Imminent demise futility
       • failure to prevent death in the very near future
     Lethal condition futility
       • intervention not expected to impact fatal outcome
         in near future due to underlying condition
     Qualitative futility
       • intervention not expected to result in an acceptable
         quality of life
           Pro-futility arguments
   Professional Integrity
       Physicians should not be forced into providing
        treatments they believe offer no benefit or are
        potentially harmful
   Professional Expertise
       Pts seek the advice of a physician regarding diagnosis
        and treatment options and would not normally expect to
        be offered Tx w/ little or no benefit
   Resource Stewardship
       Selective use of limited resources to maximize societal
            Anti-futility Arguments
   Respect for Pt Autonomy
       Where the goals of Tx, or odds of success worth
        pursuing are perceived differently by the physician
        and the pt or substitute decision makers, the latter’s
        wishes should be respected
   Prognostic Uncertainty
       Literature of critically ill pts suggests physicians are
        not good at accurately predicting outcomes making it
        difficult to justify withholding care based on this
   Lack of Societal Consensus on Futility
       Unless universally agreed upon, no futility judgments
        should be imposed on unwilling subjects
            Approach to Futility
 Patient Preferences
 Likelihood of medical benefit
     Based on literature
 Likelihood   of non-medical benefits
     Includes family needs, grieving process etc
 Family Wishes
 Potential Risks of Intervention
     Risks to pt and healthcare workers
Demands for Inappropriate Care
 Three    groups:
     Demands for ineffective Tx
       • E.g. antibiotics for common cold
     Demands for effective Tx that supports a
      controversial goal
       • E.g. liver transplant for 104 yo pt w/ end-stage
         liver dz
     Cases at the fringe of standard medical
       • E.g. chelation therapy
Demands for Inappropriate Care
 You  are under no obligation to provide Tx
  that falls outside the standard of care, or
  those for which there is very poor
  evidence but which may be used by a
  small number of physicians
 If an acute situation is complex, possibly
  inappropriate requests for life-saving
  measures should be respected
Demands for Inappropriate Care
 Demands  for effective Tx that supports a
 controversial goal
     Most difficult situation
     Values of physician vs.. family / pt
     Autonomy vs.. distributive justice
 Often   requires extensive discussions & help
     Hospital ethics committee
     Social workers
     Clergy
                    Case 19
   A 75 yo male is brought in by EMS. He was
    found comatose in his bed next to an empty
    bottle of barbiturates by a home care nurse. His
    son arrives and tells you his father has
    advanced lung CA with extensive bony mets
    which cause him intractable pain despite
    massive narcotic use. He is expected to die
    within the next 6 mo and has repeatedly stated
    the he is “ready to face the maker”. Your pt at
    that point goes into resp arrest. The son pleads
    with you not to intervene. “Please, just let him
    go. He wants to die…..has he not suffered
            The BIG Question
 Aresome suicides reasonable decisions
 rooted in the concept of autonomy?
     90% of suicides felt to be associated w/ some
      form of mental illness on post-mortem review
     Beneficience in the form of intervention
      overrules pt autonomy in these cases based
      on the idea that the mentally impaired pt the
      lacks capacity
     Situations where an otherwise competent pt
      chooses suicide are less straightforward
Are there “good” reasons for a pt to commit
   suicide? Should these be respected?
 Pro
     A pt who has capacity has the right to self-
      determination & should not suffer the
      imposition of others moral beliefs
     If all other medical options (beneficience)
      have been exhausted then our next duty
      should be to avoid further harm (maleficience)
     We must clearly differentiate between our
      own moral belief system and the choices we
      would make for ourselves, and those of our
Are there “good” reasons for a pt to commit
   suicide? Should these be respected?
 Con
     Suicide is counter to the principle of
      preserving life
     Controversial whether suicide can truly
      represent a rational choice
     Not legally recognized as a right
     Rejected by most major religions
     In the ED in particular knowledge of the pt
      and their circumstances limited
      Physician Assisted Suicide
 Legal in Netherlands & Oregon
 Not legal in Canada…yet
 Impact on ED
     Failed suicide attempts – who do we
     Family members demanding resuscitation
     Staff unable to comply with pts wish to die
     Conflict b/w members of health care team
     Conflict w/ institutional policy
         Intervening in Suicide
 Catch   22: the need to avoid 2 mistakes
     Intervening when it is not warranted
     Not intervening when it is warranted
 Bottom    line:
     ~90% will have mental illness, combined with
      the lack of prior intimate knowledge of the pt
      alone should prompt intervention given the
      irreversibility of suicide
And finally…the biggest question
                     Is this ethical, for
                     healthcare workers
                     to smoke?
                 Case 20
 51  yo male presents w/ 2 hr CP
 2 mm STE in ant leads
 Tx w/ ASA, nitro – r/o contraindications to
 During risks & benefits discussion his pain
  resolves & ECG normalizes – CCU consult
 2 hrs later nurse tells you pt is attempting
  to leave b/c his pain has resolved and he
  is tired of waiting around

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