Chapter 3 Medical, Legal, and Ethical Issues

Principle of health professions: To do NO further harm.

Avoid legal issues by acting in good faith AND up to the standard of care.

v  Consent

§  Patient autonomy

·       Able to make informed decisions on their own.

Ø  Types of consent

§  Expressed consent

·       Verbally acknowledges permission for care/transport

·       w/o explanation of treatment, risks, and benefits.

§  Informed consent

·       Expressed consent + EMT explains treatment, risks, and benefits.

·       Explanations and understanding

§  Implied consent (Aka emergency doctrine)

·       Patients who are unconscious/unable to make informed decisions

·       Used only when there is threat to life/limb.

§  Involuntary consent

·       May apply to

¨     Mentally ill patients

¨     Patients with behavioral crisis

¨     Developmentally delayed patients

·       Usually hope to gain consent from guardian prior

¨     When NOT possible, provide care under local provisions and utilize law enforcement when possible.

§  Minors and consent

·       Parent/legal guardian gives consent

·       Some states allow for emancipated minors to give their own consent

¨     Married

¨     Part of the arm forces

·       In schools, teachers and school officials may act in replacement of parents.

·       If NO consent given or lacking consent, treat as implied consent.

v  Forcible Restraint

Ø  Sometimes necessary with combative patient

Ø  Usually best to involve law enforcement or medical control

v  Refusal of care

Ø  requires:

§  Patient conscious

§  Rational

§  Capable of making informed decisions

Ø  Patient can withdraw from treatment at any time.

Ø  Assess the patient’s ability to make an informed decision.

Ø  Prior to leaving a scene b/c of refusal of care (rare) à Usually better and more easier to provide care than NOT give care at all.

§  Encourage pt to obtain treatment again

§  Ask them to sign refusal of care

§  Obtain signature from non-EMS witness.

v  Confidentiality – Health Insurance Portability and Accountability Act (HIPPA)

Ø  Patient information can only be disclosed if:

§  Patient signs a release

§  Legal subpoena is presented

§  Needed by billing dept

v  Advanced Directives

Ø  Do Not Resuscitate (DNR) à Physician written order to withhold resuscitation.

Ø  Must document:

§  Statement of patient’s medical problems.

§  Signature of patient/legal guardian

§  Signature of physician/healthcare provider

§  NOT expired.

Ø  Health care directives/Health care proxies

§  Advanced directives specifies treatment when patient unable to make decisions.

·       Physician orders for life-sustaining treatment (POLST)

·       Medical orders for life-sustaining treatment (MOLST)

·       Durable power of attorney for healthcare (healthcare proxy)

v  Physical Signs of Death

Ø  Presumptive signs of death

§  Unresponsiveness to painful stimuli

§  Lack of carotid pulse

§  Absence of chest rise and fall

§  No corneal reflexes

§  No systolic BP

§  Profound cyanosis

§  Lowered/decreased body temp

Ø  Definitive signs of death

§  Obvious mortal injury (decapitation)

§  Dependent lividity (blood settles are lowest point in the body)

§  Rigor motris (muscle stiffening for a period after death)

§  Putrefaction (decomposition)

Ø  Medical Examiner Cases – Medical professional trained to investigate unusual deaths

§  Dead on arrival (DOA) / dead on scene (DOS)

§  Death with without previous medical care

§  Suicide

§  Violent death

§  Poisoning

§  Death from accidents

§  Suspicion of a criminal act

§  Infant and child deaths

EMT Standards of Care

v  Scope of practice

Ø  DEF: Outlines care you can provide

Ø   Medical director defines scope of practice by developing:

§  Protocols

§  Standing orders

v  Standards of Care – manner that a reasonable EMT in a similar situation would do.

Ø  Established by:

§  Local custom

§  Law

§  Professional/institutional standards

§  Textbooks

§  Standards imposed by states

Possible Legal Charges

v  Negligence (Requires 4 prereqs) – Failure to provide sufficient care.

Ø  Duty to act

§  EMT has responsibility to provide patient care

·       Once ambulance responds to a call

·       When treatment has started

§  Most cases when off duty there no responsibility is to act

Ø  Breach of duty

§  EMT did not act within an expected reasonable standard of care.

Ø  Damages

§  Patient was physically or psychologically harmed in a noticeable way.

Ø  Causation

§  Cause & effect relationship exists between breach of duty & damages to patient.

v  Abandonment – Termination of care by EMT w/o patient’s consent AND w/o making provisions for care to be continued by a competent medical professional.

Ø  Can take place:

§  At the scene

§  In the hospital emergency department.

Ø  ALWAYS obtain a signature of the person accepting transfer of care at the hospital.

v  Assault and Battery

Ø  Assault – Threatening to use physical force or immediate bodily harm.

§  Ex: threatening to use restraints on the patient

Ø  Battery – Physical touching without permission.

§  Ex: providing care w/o consent

v  Kidnapping – Seizing, confining, abducting, or carrying away by force.

§  Ex: transporting patient w/o consent

v  False imprisonment – Unauthorized confinement of a person.

§  Ex: Patient rescinds consent, but EMTs do NOT let patient leave ambulance.

v  Defamation – Communication of false information that damages the reputation of the person.

Ø  Libel (written) – Ex: False statement on a run report.

Ø  Slander (spoken) – Ex: Inappropriate comments made during conversation.

v  Good Samaritan Laws – When reasonably providing care, NOT liable for errors or omissions in giving care.

Ø  Protected when:

§  Acted in good faith

§  NO expectation of compensation

§  Within scope of practice

§  Did NOT act in grossly negligent manner

When it comes to legal, paper and documents are EVERYTHING.

v  Action NOT recorded = NOT done.

v  Incomplete/untidy reports = Poor emergency care in eyes of court.

v  When subpoenaed to testify in court

Ø  Notify:

§  Service director

§  Legal counsel

Ø  As witness:

§  Remain neutral

§  Review the written report BEFORE court (less surprises)

Ø  As a defendant, an attorney is required.

§  Defenses against possible lawsuits:

·       Statue of limitations – Time limit for case to be open about the incident (past the time limit)

·       Governmental immunity – Governmental entities protected (Cannot be sued at all/amount of monetary judgment is limited).

·       Contributory negligence – Conduct of the plaintiff contributed to the injuries/damages suffered by the plaintiff (Patient’s own behavior caused their health consequences).

§  Discovery – Both sides sniff out for additional evidence about what happened

·       Interrogatories

¨     Written requests/questions

·       Depositions

¨     Oral requests/questions

Ø  Trial

§  Most cases are settled after discovery phase.

§  IF case goes to trial:

·       Compensatory damages – plaintiff compensated for injuries sustained.

·       Punitive damages – Defendant punished for behavior

§  Should mostly be covered by EMS carrier/insurance.

·       Criminal offenses – Much more serious.

Some states have mandatory reporting obligations regarding specific situations encountered:

Some examples:

·       Child/elderly abuse

·       Injury during felony

·       Drug-related injuries

·       Childbirth

·       Attempt suicide

·       Dog bites

·       Certain communicable diseases

·       Domestic violence

·       Sexual assault/rape

·       Exposure to infectious disease

·       Restrained patients

·       Crime scenes

v  Ethics

Ø  Ethics – philosophy of right & wrong, moral duties, ideal professional behavior.

Ø  Morality – Code of conduct affecting character, conduct, and conscience.

Bioethics – Address issues of ethics in healthcare.