NUBE 2025

We will walk through the case of a 10 year old child with a psychiatric history of complex PTSD, ADHD and DMDD presenting to the emergency department for “aggression”. The patient spent 20+ days boarding until a residential placement was found. In those days, there were more than 30 workplace violence injuries, 50 violent restraint episodes, and countless brainstorming sessions. When the “going got tough” and the facilities' process, resiliency, and resources were challenged, “the tough got going”. A multi-disciplinary team came together to optimize pharmacotherapy, behavior modification, therapies, and other modalities to remain true to our mission and “do what is right for kids”.

Learning Objectives:

Identify pharmacologic options for agitation.

Self report increase knowledge related to care of complex pediatric patients.

Self report increase in knowledge of non-pharmacologic agents of behavioral change.

Ethical issues, particularly those involving respect for patient autonomy, arise in emergency psychiatry practice all the time. Most clinicians working in this setting recognize that there is an ethical component when a patient is committed or determined to lack capacity to make their own medical decisions. In these cases we determine there is a good reason to override the person’s autonomy. Yet, the ethical issues are woven into the clinical care so tightly when the illness is directly impacting the patient’s ability to make decisions for themselves, that we often simply do not think about them. We think of ethics as the discussion of the complicated cases that cause disagreement among staff or catch media attention and we do not examine the ethics of the small decisions we make all of the time. If we did recognize and take a few minutes to explore these small decisions in everyday practice, we might discover that some are driven by systemic issues of bias toward our patients that have been written into our processes and procedures. Recognizing this may be the first step we can take in working toward change.

As an emergency psychiatrist who has recently completed a degree in bioethics, I now notice the small things we do every day that have ethical ramifications and deserve our attention. And I see how some of the dilemmas we face are created by how we do our work. Can we change? Maybe, but first we must see the problems. We are all busy doing our day-to-day work and stepping back to examine underlying ethical concerns is difficult. Thinking of ethics in the context of everyday work rather than as something separate and associated with only the complicated cases may help us provide better and more ethical care.

In this brief “rapid fire” presentation, I want to encourage audience members to recognize and begin to examine the small things, the “microethics” of our everyday practice. I will start by reviewing the concept of what is referred to as micro or everyday ethics in medical practice and will then use a case or two to further illustrate my points. This will be followed by a few minutes for audience members to share their own stories of every day ethical decisions. My hope is that this presentation and brief discussion will simply be a first step in beginning to think about ethics in our everyday interactions, while considering how this information can help us address procedural issues.

Learning Objectives:

Define microethics, the ethics of everyday clinical practice.

Identify an ethical issue in your everyday practice and explain why it is an ethical issue.

Explain how recognizing a microethics issue can help you identify underlying processes and procedures that may need critical reexamination.