he had been restless in bed all night and had fallen when trying to stand that morning .
Elderly fallers make a substantial part of the ambulance service workload , and Simpson et al ( 2017 ) state that decision making is heavily influenced by the paramedic ’ s perception of the role and their perceived validity of these cases . Albert was alert and able to confirm that he had no injuries , so he was assisted to a seated position . Once in this position however , it was immediately apparent that he was very unwell . Although alert , he was ashen and diaphoretic with a weak , rapid radial pulse . Basic observations revealed a heart rate of 130 beats per minute , blood pressure 70 / 40 mmHg and a tympanic temperature of 34.5 degrees centigrade .
The initial impression was that this was likely to be sepsis ( National Institute for Health & Care Excellence ( NICE ), 2017 ) so preparations were made to rapidly move him to the ambulance for transport to hospital . While eliciting a history to identify a source of infection , Albert complained of some abdominal pain although he had no associated symptoms such as nausea or vomiting , diarrhoea or constipation . His wife offered us his current medication to inspect and stated there he was known to have a large abdominal aortic aneurysm ( AAA ) which the doctors said was inoperable . With this information Albert was quickly moved from the floor to the bed , where an abdominal assessment revealed a large pulsatile mass , and although radial pulses were still palpable , there were no detectable femoral pulses . This new information significantly changed the working diagnosis to a probable dissection of the aortic aneurysm ( Jarvis , 2015 ).
Both sepsis and dissection of the aorta are life threatening conditions . Sepsis has a mortality of around 10 % ( Singer et al , 2016 ) but can be treated aggressively to improve outcomes ( NICE , 2017 ). Aortic dissection has a mortality of around 50 % even after surgical repair ( NICE , 2009 ) however Albert had already been told that his aneurysm was inoperable . During assessment his blood pressure dropped to 55 / 30 mmHg and he was now only responding to pain .
Based on the information that his AAA was inoperable , I decided that although sudden , this was now a palliative care situation .
I explained to Albert ’ s wife that any treatment would ultimately be futile , and I felt it would be more appropriate and dignified to allow him to die peacefully at home . Although visibly distressed , she agreed . Albert was made comfortable in bed , and his wife was encouraged to sit with him as he passed away . Sheffield et al ( 2016 ) found that a holistic approach to care is a key factor in decisions by paramedics not to transport patients
The phrases ‘ clinical reasoning ’, ‘ clinical judgement ’, ‘ clinical decision making ’ and ‘ critical thinking ’ are often used interchangeably ( Shaban , 2005 ). However , convention suggests that clinical reasoning is the stage in which clinicians gather and process information , clinical decision making refers to the diagnosis or treatment plan ( Levett-Jones et al , 2010 ) and critical thinking is the cognitive ability needed to perform this ( HEE , 2017 ). Levett-Jones et al ( 2010 ) promote a clinical reasoning cycle which organises information gathering and processing into eight logical steps . First , initial information about the patient and presenting complaint must be sought . In Albert ’ s case , this appeared to simply be an 80 year old male who had fallen . After this , more information must be gathered ; history of the presenting complaint , past medical history , vital signs and results of investigations . It was during this stage that Albert ’ s vital signs alerted me to the severity of his condition . treatment goals would have been aggressive management and rapid transport to hospital .
The boundaries between each stage are not clear cut , and clinicians often combine stages or move back and forth between them to assimilate enough information before a decision is reached ( Levett-Jones et al , 2010 ). This appears to be what happened in the case presented .
Now , treatment goals were very different . Mortality from AAA rupture has long been known to be certain without surgical repair ( Johanssen & Swedenborg , 1986 ), and this instance was known to be irreparable . Knowing death was both inevitable and imminent ( Wahlberg & Goldstone , 2017 ), a plan had to be made which was both appropriate and compassionate .
The classical or normative decision-making paradigm ( Edwards , 1954 ; Hammond , 1955 ) describes a situation with a clearly defined