Chapter 3 Medical, Legal, and Ethical Issues

Chapter 3 Medical, Legal, and Ethical Issues

Introduction (1 of 2) A basic principle of emergency care is to do no further harm. A health care provider usually avoids legal exposure if he or she acts: – In good faith – According to an appropriate standard of care

Introduction (2 of 2) The EMT is often the first link in the chain of prehospital care. Litigation against EMS will increase due to wider availability and more complex care.

Consent (1 of 2) Consent is permission to render care. A person must give consent for treatment. If the patient is conscious and rational, he or she has a legal right to refuse care.

Consent (2 of 2) Foundation of consent is decision-making capacity. – Can understand information provided – Can make informed choice regarding medical care Patient autonomy is right of patient to make decisions about his or her health.

Expressed Consent Patient acknowledges he or she wants you to provide care or transport. To be valid, patient must provide informed consent. – You have explained treatment, risks, and benefits to patient.

Implied Consent (1 of 2) Applies to patients who are – Unconscious – Otherwise incapable of making informed decision Source: Dan Myers

Implied Consent (2 of 2) Should never be used unless there is a threat to life or limb. Principle of implied consent is known as the emergency doctrine. Good to get consent from a spouse or relative.

Involuntary Consent Applies to patients who are: – Mentally ill – In behavioral crisis – Developmentally delayed Obtain consent from guardian – Not always possible, so understand local provisions

Minors and Consent (1 of 2) Parent or legal guardian gives consent. In some states, a minor can give consent. – Depending on age and maturity – Emancipated minors (married, armed services, parents) Teachers and school officials may act in place of parents.

Minors and Consent (2 of 2) If true emergency exists, and no consent is available: – Treat the patient. – Consent is implied.

Forcible Restraint (1 of 2) Sometimes necessary with combative patient

Forcible Restraint (2 of 2) Is legally permissible – But generally you must consult medical control for authorization. – In some states, only a law enforcement officer may forcibly restrain.

The Right to Refuse Treatment (1 of 2) Conscious, alert adults with decisionmaking capacity: – Have the right to refuse treatment – Can withdraw from treatment at any time – Even if the result is death or serious injury Places burden on EMT to clarify need for treatment

The Right to Refuse Treatment (2 of 2) Before you leave a scene where a patient, parent, or caregiver has refused care: – Encourage them again to allow care. – Ask them to sign a refusal of care form. – Document all refusals. – A witness is valuable in these situations.

Confidentiality (1 of 2) Information should remain confidential. Information generally cannot be disclosed except: – If patient signs a release – If legal subpoena is presented – If it is needed by billing personnel

Confidentiality (2 of 2) HIPAA (Health Insurance Portability and Accountability Act of 1996) – Contains a section on patient privacy – Strengthens privacy laws – Safeguards patient confidentiality – Considers information to be protected health information (PHI)

Advance Directives (1 of 3) Advance directive specifies treatment should the patient become unconscious or unable to make decisions. A do not resuscitate (DNR) order is an advance directive that gives permission not to resuscitate. – “Do not resuscitate” does not mean “do not treat.”

Advance Directives (2 of 3) Advance directive is also called: – Living will – Health care directive

Advance Directives (3 of 3) Some patients may have named surrogates to make decisions for them. – Durable powers of attorney for health care – Also known as health care proxies

Physical Signs of Death (1 of 4) A physician determines cause of death. Presumptive signs of death: – Unresponsiveness to painful stimuli – Lack of a carotid pulse or heartbeat – Absence of breath sounds – No deep tendon or corneal reflexes

Physical Signs of Death (2 of 4) Presumptive signs of death (cont’d): – Absence of eye movement – No systolic blood pressure – Profound cyanosis – Lowered or decreased body temperature

Physical Signs of Death (3 of 4) Definitive signs of death: – A body in parts (decapitation) – Dependent lividity (blood settling)

Physical Signs of Death (4 of 4) Definitive signs of death (cont’d): – Rigor mortis (stiffening) – Putrefaction (decomposition)

Medical Examiner Cases (1 of 2) Involvement depends on nature/scene of death. Examiner notified in cases of: – Dead on arrival (DOA)/dead on scene (DOS) – Death without previous medical care – Suicide – Violent death

Medical Examiner Cases (2 of 2) Examiner notified in cases of (cont’d): – Poisoning, known or suspected – Death from accidents – Suspicion of a criminal act Source: Corbis

Special Situations (1 of 4) Organ Donors – Expressed a wish to donate organs – Evidenced by information on: Organ donor card and/or Driver’s license – Your priority is to save patient’s life. – Remember that organs need oxygen.

Special Situations (2 of 4) Organ Donor card Source: Courtesy of the U.S. Department of Health and Human Services

Special Situations (3 of 4) Medical identification insignia – Bracelet, necklace, or card indicating: DNR order Allergies Diabetes, epilepsy, or other serious condition Helpful in patient assessment and treatment

Special Situations (4 of 4) Medical identification insignia Source: Courtesy of the MedicAlert Foundation . 2006, All Rights Reserved. MedicAlert is a federally registered trademark and service mark.

Scope of Practice (1 of 3) Outlines the care you are able to provide Usually defined by state law

Scope of Practice (2 of 3) Medical director further defines by developing: – Protocols – Standing orders

Scope of Practice (3 of 3) Carrying out procedures outside scope of practice may be considered: – Negligence – Criminal offense

Standards of Care (1 of 3) Manner in which you must act or behave You must be concerned about safety and welfare of others.

Standards of Care (2 of 3) Standards of care established by: – Local custom – Statutes Protocols – Professional or institutional standards Example: AHA CPR guidelines – Textbooks Example: NHTSA

Standards of Care (3 of 3) Standards of care established by (cont’d): – Standards imposed by states Medical Practices Act Certification Licensure

Duty to Act Individual’s responsibility to provide patient care Duty to act applies: – Once your ambulance responds to a call – Treatment is begun

Negligence (1 of 2) Failure to provide same care that person with similar training would provide in same or similar situation.

Negligence (2 of 2) All four of the following elements must be present for negligence to apply: – Duty – Breach of duty – Damages – Causation

Abandonment Unilateral termination of care by EMT without: – Patient’s consent – Making provisions for continuing care Abandonment may take place: – At scene – In emergency department

Assault and Battery, and Kidnapping (1 of 2) Assault: Unlawfully placing person in fear of immediate bodily harm – Example: restraint Battery: Unlawfully touching a person – Example: providing care without consent

Assault and Battery, and Kidnapping (2 of 2) Kidnapping: Seizing, confining, abducting, or carrying away by force – Example: transport against will – A false imprisonment charge is more likely (defined as unauthorized confinement of a person).

Defamation (1 of 2) Communication of false information that damages reputation of a person – Libel if written – Slander if spoken

Defamation (2 of 2) Defamation could happen with: – False statement on a run report – Inappropriate comments made during conversation Run report should be accurate, relevant, and factual.

Good Samaritan Laws and Immunity (1 of 2) If you reasonably help another person, you will not be held liable for error/omission Good Samaritan actions to be met: – Good faith – Without expectation of compensation – Within scope of training – Did not act in grossly negligent manner

Good Samaritan Laws and Immunity (2 of 2) Gross negligence is conduct that constitutes willful or reckless disregard. There is another group of laws that grants immunity from liability to official providers. – Laws vary; always consult with the medical director.

Records and Reports (1 of 3) Compile record for all incidents involving sick or injured patients Important safeguard against legal complications

Records and Reports (2 of 3) Courts consider: – An action not recorded was not performed – Incomplete or untidy reports is evidence of poor emergency medical care

Records and Reports (3 of 3) This image shows proper documentation (left) and improper documentation (right).

Special Mandatory Reporting Requirements (1 of 3) Most states have a reporting obligation: – Abuse of children, older persons, and others – Injury during commission of a felony – Drug-related injuries – Childbirth

Special Mandatory Reporting Requirements (2 of 3) Most states have a reporting obligation (cont’d): – Attempted suicides – Dog bites – Communicable diseases – Assaults – Domestic violence

Special Mandatory Reporting Requirements (3 of 3) Most states have a reporting obligation (cont’d): – Sexual assault – Exposures to infectious disease – Transport of patients in restraints – Scene of a crime – The deceased

Ethical Responsibilities (1 of 2) Ethics: Philosophy of right and wrong, moral duties, ideal professional behavior Morality: Code of conduct affecting character, conduct, and conscience. Bioethics: Specifically addresses issues that arise in practice of health care

Ethical Responsibilities (2 of 2) Requires you to evaluate and apply ethical standards – Your own – Those of the profession Be honest in reporting. Keep accurate records.

The EMT in Court (1 of 5) You can end up in court as a: – Witness – Defendant Case can be civil or criminal. Source: Photodisc

The EMT in Court (2 of 5) Whenever called to testify, notify: – Your service director – Legal counsel As witness: – Remain neutral – Review run report before court

The EMT in Court (3 of 5) As a defendant, an attorney is required. Defenses may include: – Statute of limitations – Governmental immunity – Contributory negligence

The EMT in Court (4 of 5) Discovery allows both sides to obtain more information through: – Interrogatories Written requests or questions – Depositions Oral requests or questions

The EMT in Court (5 of 5) Most cases are settled following the discovery phase during the settlement phase. If not settled, the case goes to trial Damages that may be awarded: – Compensatory damages – Punitive damages