Chapter 3 - Medical, Legal and Ethical Issues

Explain the reporting requirements for special situations, including abuse, drug or felony-related injuries, childbirth, and crime scenes

- Abuse / neglect of children, elderly, and others-Injury during the commission of a felony -Sexual Assault -Mentally incompetent -Drug related injury -Childbirth -Infectious disease exposure -Death >>>Mandatory reporting laws vary by locality<<<* Mandated reporting in Massachusetts

Describe the roles and responsibilities of the EMT in court

- EMTs may be witnesses or defendants in civil or criminal cases. -If you are subpoenaed, notify your service director and legal counsel. -As a witness, you may be required to review the run report as evidence. - You may be deposed (interviewed) as part of discovery. - Most medical cases do not go to trial but are settled after discovery. -EMTs who are defendants often use statutes of limitations (limits on how much time can pass between an incident and lawsuit), governmental immunity based upon state laws, or contributory negligence (the patient is at least partially to blame for the injury/damages). -Cases that go to trial can award compensatory damages (intended to repay proportionally to the injury) and punitive damages (intended to deter the defendant or others from similar actions).

Discuss the importance of do not resuscitate orders and local protocols as they relate to the EMS enviornment

- Patient has the right to refuse resuscitative efforts - In general, requires written physician order - Become familiar with state and local protocols - When in doubt, resuscitate - Massachusetts uses the "Comfort care" form - EMTs in MA require a Comfort Care form or MOLST in order to honor a DNR

While emergency medical care is being provided, you must be careful not to disturb the scene of the crime any more than absolutely necessary

- notes and drawings should be made of the position of the patient and of the presence and position of any weapon or other objects that may be valuable to the investigating officers - if possible, do not cut through holes in clothing that were caused by weapons or gunshot wounds - avoid walking through blood and try to avoid leaving footprints in the dirt or grass at or near a crime scene

Negligence elements

1. Duty 2. Breach 3. Causation 4. Damages

Discuss the EMTs role and obligations if a patient refuses treatment or transport

Adults who are conscious, alert, and appear to have decision making capacity have the right to refuse treatment or withdraw from treatment at any time. A patient's decision to either accept or refuse treatment should be based on information that you provide. This information should include: - Your assessment of what might be wrong with the patient - A description of the treatment that you feel is necessary - Any possible risks of the treatment - The ability of alternative treatments - Possible consequences of refusing treatment Assure the patient understands everything you say. Encourage the patient to ask questions. You should involve online medical control and document the consultation. Everything you say should be included in the patient care report. Have a witness sign form to help protect you from a later claim for negligence or abandonment.

Describe the relationship between patient communications, confidentiality, and the HIPAA

Communication between you and the patient is considered confidential and generally cannot be disclosed without permission from the patient or a court order. Confidential information includes: - The patient history - Assessment Findings - Treatment provided HIPAA aims to strengthen laws for the protection of the privacy of health information and to safeguard patient confidentiality. Protected health information (PHI)

Which of the following gives surrogates the right to make decisions for patients regarding their health care in the event that the patient is incapacitated and unable to make such decisions?

Durable power of attorney for health care

Describe the EMTs legal duty to act

Duty to act is an individual's responsibility to provide patient care. There may be a duty to act in certain instances, including the following: - You are charged with emergency medical response - Your service or department's policy states that you must assist in any emergency

Define ethics and morality and their implications for the EMT

Ethics: The philosophy of right and wrong, of moral duties, and of ideal professional behavior. Morality: code of conduct that can be defined by society, religion, or a person, affecting character, conduct, or conscience.

Define consent and how it relates to decision making

In the context of EMS, consent is permission to render care The foundation of consent is decision making capacity. Decision Making capacity is the ability of a patient to understand the information you are providing, coupled with the ability to process that information and make an informed choice regarding medical care.

Compare expressed consent, implied consent, and involuntary consent

Informed Consent: Permission for treatment given by a competent patient after the potential risks, benefits, and alternatives to treatment have been explained. Expressed Consent: type of consent given when the patient verbally or otherwise acknowledges that he or she wants you to provide care or transport. Can be verbal or nonverbal. Implied Consent: type of consent in which a patient who is unable to give consent is given treatment under the legal assumption that he or she would want treatment Involuntary Consent: type of consent in which a patient is in some way incapacitated and care is given against their will. This is consent given by a guardian or conservator for patients who are in a behavioral crisis/emergency or developmentally delayed

Discuss consent by minors for treatment or transport

Minors require a parent or guardian's expressed consent. If in a life threatening emergency in the absence of a parent/guardian, implied consent applies If a minor is injured and requires medical treatment in a school or camp setting, teachers and school officials may act in loco parentis, which means in the position or place of a parent, and can legally give consent for treatment of the minor if a parent or guardian is not available.

Discuss the issues of negligence, abandonment, assault and battery, and kidnapping and their implications for the EMT

Negligence is the failure to provide the same care that a person with similar training would provide in the same or similar situation. Determined based on the following four factors: 1. Duty. 2. Breach of duty. 3. Damages. 4. Causation. Abandonment is unilateral termination of care by the EMT without the patient's consent and without making any provisions for continuing care by a medical professional who is competent to provide care for the patient. Assault is defined as unlawfully placing a person in fear of immediate bodily harm. Battery is defined as unlawfully touching a person; this includes providing emergency care without consent. Kidnapping is the seizing, confining, abducting, or carrying away of a person by force.

Recognize the importance of medical identification devices in treating the patient

Patients may carry important medical information and identification in the form of: - A bracelet - Necklace - Key chain - ID card May include DNR order or information related to meds taken, allergies, diabetes, epilepsy, or some other serious condition. Some have USB flash with PDF files containing pertinent information.

Describe the physical, presumptive, and definitive signs of death

TRAUMA INCONSISTENT WITH LIFE: -Decapitation -Transection of the torso -Complete destruction of the brain or heart-Incineration -Cardiac arrest clearly and unequivocally caused by significant blunt or penetrating trauma (Exception: Penetrating chest trauma with short transport time to definitive care) Presumptive Signs of Death: - Unresponsiveness to painful stimuli - Lack of a carotid pulse or heart beat - Absence of chest rise and fall - No deep tendon or corneal reflexes - Absence of pupillary reactivity - No systolic blood pressure - Profound cyanosis - Lowered or decreased body temperature Definitive signs of Death: - Obvious mortal damage, such as decapitation - Dependent lividity: Blood settling to the lowest point of the body, causing discoloration of the skin. - Rigor mortis: the stiffening of the body muscles caused by chemical changes w/i the muscle tissue. Occurs sometime between 2-12 hours after death. - Putrefaction (decomposition of body tissues): Depending on temperature conditions, this occurs sometime between 40-96 hours after death.

Discuss the scope of practice and standards of care

The scope of practice, which is most commonly defined by state law, outlines the care you are legally able to provide for the patient. Your medical director defines the scope of practice by developing protocols and standing orders. The manner in which you must act or behave is called a standard of care.

Describe local EMS system protocols for using forcible restraint

Typically, you should consult medical control for authorization to restrain or contact law enforcement personnel who have the authority to restrain people. Restraint may only be used in circumstances of risk to the patient or others. MGL Chapter 111 Section 18 says "an emergency medical technician may restrain a patient who presents an immediate or serious threat of bodily harm to himself or others," which must be documented.

Explain how to manage patients who are identified as organ donors

You should treat a potential organ donor in the same way that you would any other patient needing treatment. Use all means necessary to keep that patient alive. You must give oxygen to keep organs viable.

Morality

a code of conduct that can be defined by society, religion, or a person, affecting character, conduct, and conscience

Contributory negligence

a legal defense that may be raised when the defendant feels that the conduct of the plaintiff somehow contributed to any injuries or damages that were sustained by the plaintiff

Duty to act

a medicolegal term relating to certain personnel who either by statute or by function have a responsibility to provide care

Emancipated minor

a person who is under the legal age in a given state but, because of other circumstances, is legally considered an adult

Emergency

a serious situation, such as injury or illness, that threatens the life or welfare of a person or group of people and requires immediate intervention

Medicolegal

a term relating to medical jurisprudence (law) or forensic medicine

Negligence per se

a theory that may be used when the conduct of the person being sued is alleged to have occurred in clear violation of a statute

Durable power of attorney for health care

a type of advance directive executed by a competent adult that appoints another individual to make medical treatment decisions on his or her behalf in the event that the person making the appointment loses decision-making capacity

Health care proxy

a type of advance directive executed by a competent adult that appoints another individual to make medical treatment decisions on his or her behalf in the event that the person making the appointment loses decision-making capacity. Also known as a durable power of attorney for health care

Expressed consent

a type of consent in which a patient gives verbal or nonverbal authorization for provision of care or transport

Health care directive

a written document that specifies medical treatment for a competent patient, should he or she become unable to make decisions. Also known as an advance directive or a living will

While evaluating a noncritical patient in the field, you received a call from dispatch about a serious four-car accident. You inform the patient whom you are treating that he should have someone take him to his doctor to get checked out; you then leave to attend to the more seriously injured people. This is an example of:

abandonment

Decision-making capacity

ability to understand and process information and make a choice regarding appropriate medical care

Competent

able to make rational decisions about personal well-being

Which of the following is an example of abandonment?

an AEMT transfers care of a patient to an EMR

Once care is started, you have assumed a duty that must not stop until...

an equally competent medical provider assumes responsibility

Protected Health Information (PHI)

any information about health status, provision of health care, or payment for health care that can be linked to an individual. This is interpreted rather broadly and includes any part of a patient's medical record or payment history

DNRs

are only for the end of stage of life, terminal or expecting death

Dependent lividity

blood settling to the lowest point of the body, causing discoloration of the skin which is a definitive sign of death

Gross negligence

conduct that constitutes a willful or reckless disregard for a duty or standard of care

You belong to a small volunteer EMS company and are treating a patient with chest pain. You believe that the administration of aspirin is indicated. You ask the patient if he is allergic to aspirin and he says no. Shortly after you administer the aspirin, the patient develops signs and symptoms of a severe allergic reaction. Later in the hospital, the doctor advises you that the patient's medical history shows that the patient has an allergy to aspirin. The patient later sues you. Which of the following is your best defense strategy?

contributory negligence

Algor mortis

cooling of the body after death until it matches the ambient temperature

Compensatory damages

damages awarded in a civil lawsuit that are intended to restore the plaintiff to the same condition that he or she was in prior to the incident

Punitive damages

damages that are sometimes awarded in a civil suit when the conduct of the defendant was intentional or constituted a reckless disregard for the safety of the public

Putrefaction

decomposition of body tissues; a definitive sign of death

_____ is an obvious sign of death, which is caused by discoloration of the body from pooling of the blood to the lower parts of the body

dependent lividity

Breach of confidentiality

disclosure of information without proper authorization

What is the best way to care for your patient once he tells you he does not want to go to the hospital?

encourage the patient to call 9-1-1 again if his condition worsens

You arrive at the scene of an older woman complaining of chest pain. In assessing her, she holds her arm out for you to take her blood pressure. This is an example of:

expressed consent

Negligence

failure to provide the same care that a person with similar training would provide

Criminal lawsuits for battery are common in health care.

false

Defamation that is spoken is known as libel

false

The manner in which principles of ethics are incorporated into professional conduct is known as bioethics

false

Slander

false and damaging information about a person that is communicated by the spoken word

Libel

false and damaging information about a person that is communicated in writing

You have responded to a vehicle accident call. Initially, the male patient allows you to splint his broken arm and complete a primary assessment. However, he rescinds consent during transport and demands to be let out of the ambulance. If you refuse, which of the following might you be charged with?

false imprisonment

A basic medical, legal and ethical principle of emergency care is to...

first do no further harm

Two general rules regarding reports and records:

if action or procedure is not recorded on the written report, it was not performed an incomplete or untidy report is evidence of incomplete or inexpert emergency medical care

Emergency medical care

immediate care or treatment

_________ occurs when a person is unconscious or otherwise incapable of making a rational, informed decision about care and is unable to give consent; the law assumes that the patient would consent to care and transport to a medical facility if he or she were able to do so

implied consent

______ occurs when an adult patient who is mentally incompetent is not able to give informed consent. Consent for emergency care should be obtained from someone who is legally responsible for the patient, such as a guardian or conservator

involuntary consent

Government immunity

legal doctrine that can protect an EMS provider from being sued or which may limit the amount of the monetary judgment that the plaintiff may recover; generally applies only to EMS systems that are operated by municipalities or other governmental entities

Many states consider minors to be emancipated if they are:

members of the armed services, or if they are parents

Scope of practice

most commonly defined by state law; outlines the care you are able to provide for the patient

Definitive signs of death

obvious mortal damage dependent lividity rigor mortis algor mortis putrefaction

Depositions

oral questions asked of parties and witnesses under oath

Consent

permission to render care

Which of the following should you do to avoid serious ethical or legal issues related to social media posts?

recognize that free speech does not mean every person has a right to say anything under any circumstances and without repercussions

In loco parentis

refers to the legal responsibility of a person or organization to take on some of the functions and responsibilities of a parent

Adults who are conscious, alert, and appear to have decision-making capacity have the right to...

refuse treatment or withdraw from treatment at any time, which is supported by the principal of autonomy

Good samaritan laws

statutory provisions enacted by many states to protect citizens from liability for errors and omissions in giving good faith emergency medical care, unless there is wanton, gross, or willful negligence

Rigor mortis

stiffening of the body muscles; a definitive sign of death

Forcible restraint

the act of physically preventing an individual from initiating any physical action

Defamation

the communication of false information about a person that is damaging to that person's reputation or standing in the community

False imprisonment

the confinement of a person without legal authority or the person's consent

Applied ethics

the manner in which principles of ethics are incorporated into professional conduct

When a person is unconscious or otherwise incapable of making a rational, informed decision about care and unable to give consent, the law assumes that....

the patient would consent to care and transport to a medical facility if he or she were able to do so

Discovery

the phase of a civil lawsuit where the plaintiff and defense obtain information from each other that will enable the attorneys to have a better understanding of the case and which will assist in negotiating a possible settlement or in preparing for trial. Discovery includes depositions, interrogatories, and demands for production of records

Ethics

the philosophy of right and wrong, of moral duties, and of ideal professional behavior

Emergency doctrine

the principle of law that permits a health care provider to treat a patient in an emergency situation when the patient is incapable of granting consent because of an altered level of consciousness, disability, the effects of drugs or alcohol, or the patient's age

Patient autonomy

the right of a patient to make informed choices regarding his or her health care

Kidnapping

the seizing, confining, abducting, or carrying away of a person by force, including transporting a competent adult for medical treatment without his or her consent

Bioethics

the study of ethics related to issues that arise in health care

Statute of limitations

the time within which a case must be commenced

Immunity laws, which vary from state to state, do not provide immunity when injury or damage is caused by gross negligence or willful misconduct.

true

Implied consent

type of consent in which a patient who is unable to give consent is given treatment under the legal assumption that he or she would want treatment

Abandonment

unilateral termination of care by the EMT without the patient's consent and without making provisions for transferring care to another medical professional with the skills and training necessary to meet the needs of the patient

Battery

unlawful touching of another person or providing emergency care without consent

Assault

unlawfully placing a patient in fear of bodily harm

Presumptive signs of death

unresponsive to painful stimuli lack of carotid pulse or heartbeat absence of chest rise and fall no deep tendon or corneal reflexes absence of pupil response no systolic blood pressure profound lowered or decreased body temp

Proximate causation

when a person who has a duty abuses it, and causes harm to another individual; the EMT, the agency, and/or the medical director may be sued for negligence

Res ipsa loquitur

when the EMT or an EMS system is held liable even when the plaintiff is unable to clearly demonstrate how an injury occurred

DNR (do not resuscitate)

written documentation by a physician giving permission to medical personnel to not attempt resuscitation in the event of cardiac arrest

Advance directive (AD)

written documentation that specifies medical treatment for a competent patient should the patient become unable to make decisions; also called a living will or health care directive

Interrogatories

written questions that the defense and plaintiff send to one another

Standard of care

written, accepted levels of emergency care expected by reason of training and profession; written by legal or professional organizations so that patients are not exposed to unreasonable risk or harm

Torts

wrongful acts that give rise to a civil lawsuit