The importance of reliable information exchange in emergency practices: a misunderstanding that was uncovered before it was too late.

摘要: Many medical emergency practices are regulated by written procedures that normally provide reliable guidelines for action. In some cases, however, the consequences of following rule-based instructions can have unintended negative consequences. The article discusses a case - described on type level where rule formulation could been fatal. A weak and elderly patient has cardiac arrest, Do Not Resuscitate (DNR) clause is in patient’s record. Paramedics at scene cannot see general appearance match conditions which would indicate DNR clause, so they start cardiopulmonary resuscitation (CPR), survives. This turns out to be crucial decision. from an earlier bout with serious disease recovered, against all odds, someone forgotten remove order able interpret validity guidelines, paramedics other health workers need develop personal skills transcend ability simply follow instructions. Within traditional virtue ethics, judgment conceived as being make ‘good’ autonomous decisions. Virtue ethical analyses, decision-making abilities non-technical communication important conceptual tools when difficult clinical study accentuates significance prudent practice. described, consequence trusting advance directive fatal, but point general: purpose achieving excellent organizational performance, it insufficient rely uncritically rules procedures. Even clearest formulations must interpreted contextually determine ethically correct behavior avoid potential not best interests.