Chapter 3 Medical, Legal, and Ethical Issues

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.

Implied consent

Which of the following statements about the patient care report is correct?

It is difficult to prove actions were performed if they are not included on the report.

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.

Kidnapping

Defamation is the communication of false information that damages the reputation of a person. When defamation is in writing, it is also known as:

Libel

False and damaging information about a person that is communicated in writing.

Libel

As an EMT, the standards of emergency care are often partially based on:

Locally accepted protocols

DNR orders with expiration dates must be dated within the preceding _____ to be valid.

12 months

Explain how to manage patients who are identified as organ donors.

- Consent to organ donation is voluntary and knowing. Consent is evidenced by either a donor card or a driver's license indicating that the individual wishes to be a donor. You may need to consult with medical control when faced with this situation. - Certain centers can procure organs, including the kidneys and liver, in certain situations. Be aware of your local centers and their protocols and capabilities. - 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 the patient alive. Organs that are often donated, such as a kidney, heart, or liver, need oxygen at all times; you must give oxygen to the possible donor or the organs will be damaged and become useless. - Be sure to learn what the specific protocols are in your area regarding special situations such as organ donation.

Recognize the importance of medical identification devices in treating the patient.

- Many patients will carry important medical identification and information, often in the form of a bracelet, necklace, key chain, or card that identifies patient history information. - Some patients wear medical bracelets with a USB flash drive, which contains pertinent patient information, such as drug interactions, allergies, or emergency contact information. This information is often stored as a PDF file that can be read on most computers.

Discuss consent by minors for treatment or transport.

- The law requires that a parent or legal guardian, when available, give consent for treatment or transport of a minor. - In every state, when a parent cannot be reached to provide consent, health care providers are allowed to give emergency care to a child. - In some states, a minor can consent to receive medical care, depending on the minor's age and maturity. Many states consider minor's to be emancipated if they are married, if they are members of the armed services, or if they are parents. A minor who is a parent may also give consent for his or her own child. A court may issue an order declaring a minor to be emancipated but this is not commonly seen. - 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 a minor if a parent or guardian is not available. You should still make an effort to obtain consent from a parent or legal guardian whenever possible; however, if a true emergency exists and the parent or legal guardian is not available, the consent to treat the minor is implied, just as with an adult. It is important to reach the parent or guardian as quickly as possible. Follow local protocol or consult medical control to determine if someone acting in loco parentis will need to accompany the child during transport and be present at the receiving hospital until a parent or guardian arrives.

Describe the roles and responsibilities of the EMT in court.

- Whenever you are subpoenaed to testify in any court proceeding, you should immediately notify the director of your service and legal counsel. - As a witness you should remain neutral during your testimony. - In all likelihood, many of the questions that you will be asked will be based on the documentation you wrote at the time of the incident. Be sure to review your run report prior to your court appearance. - As a defendant in either a civil or criminal proceeding, you will definitely require the assistance of an attorney. - In a civil lawsuit, where you are being sued in your capacity as an employee or volunteer of an EMS system, your service or its insurance company generally will provide you with legal counsel. - A civil lawsuit begins with the service of a summons and complaint. The complaint will set forth the details of the plaintiff's case and will provide the theory on which the plaintiff is relying to recover a judgement against you and your service. If served with a summons, you must bring this to the attention of the head of your service immediately, because the complaint must be responded to within a set period of time that is usually within 20 to 30 days. The response to the complaint is called an answer and it will generally deny the claims set forth in the complaint and set forth one or more defenses on behalf of you and your service. Depending on the nature of the case filed against you, the type of EMS system that you work for, and the state where you work, there may be different possible defenses available to you. These may include the defenses of statute of limitations, immunity, or contributory negligence. - The statute of limitations is the time within which a case must be commenced. - Governmental immunity generally applies only to EMS systems that are operated by municipalities or other governmental entities. If your service is covered by immunity, it may mean that you cannot be sued at all or it may limit the amount of monetary judgement that the plaintiff may recover. - Contributory negligence is 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. The defense of contributory negligence might be raised since it was the patient's forgetfulness and his denial of an aspirin allergy that contributed to his allergic reaction. - The next phase is known as discovery, and it is an opportunity for both sides to obtain information that will enable the attorneys to have a better understanding of the case and assist in negotiating a possible settlement or in preparing for trial. Discovery may include interrogatories, depositions, requests for production of documents, and physician examinations. - Interrogatories are written questions that each side sends to the other, and depositions are oral questions asked if parties and witnesses under oath. - On completion of the discovery phase, the parties may try to negotiate a possible settlement. If a settlement is not able to be negotiated, the case will be set for trial. - At trial, each side will have an opportunity to present evidence that includes testimony of witnesses and documents such as medical reports and your run report. Witnesses may include experts such as physicians. If a judgement is rendered against you or your service, the plaintiff may be awarded compensatory or punitive damages: 1. Compensatory damages. These damages are intended to compensate the plaintiff for the injuries he or she sustained such as medical bills, damages to personal property, lost earnings, and physical or emotional pain and suffering. 2. Punitive damages. Punitive damages are not commonly awarded in negligence cases and are deserved for those cases where the defendant has acted intentionally or with a reckless disregard for the safety of the public. In most cases, if a judgment is rendered against you, your service or its insurance carrier will pay the judgement.

Discuss the EMT's role and obligations if a patient refuses treatment or transport.

- You must be familiar with local policies regarding refusal of care. In all such cases, you should involve online medical control and document this consultation. - 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 treatment, the availability of alternative treatments, and the possible consequences of refusing treatment. Be sure that the patient understands everything that you say and encourage the patient to ask questions. All of this information should be included in your patient care report. Many jurisdictions have pre-printed refusal forms to ensure that all of these items are documented and acknowledged. - When treatment is refused, you must assess the patient's ability to make an informed decision. If the patient appears confused or delusional, you cannot assume that the decision to refuse is an informed refusal. Patients who have attempted suicide, or conveyed suicidal intent, should not be regarded as having normal mental capacity. As with most medical conditions, it is the constellation of findings that will support your conclusion. When in doubt, providing treatment is a much more defensible position than failing to treat a patient. - Before leaving a scene where a patient has refused care, you should again encourage the patient to permit treatment and remind him or her to call 9-1-1 if he or she changes his or her mind or his or her condition worsens. Advise the patient to contact his or her personal physician as soon as possible. It is essential for you to ask the patient to sign a refusal of treatment form and to thoroughly document all refusals. Your documentation should include any assessment findings that you were able to make and all efforts that you made to obtain consent. Your documentation should also include a description of possible consequences of refusing treatment and transport. The patient's signature should be witnessed by a family member or police officer to help protect you from a later claim for negligence or abandonment. - It is wise, and often required by local protocol, that you notify medical control of your actions; medical control can help guide your decisions. - You may also be faced with a situation in which a parent refuses to permit treatment of an ill or injured child. In this situation, you must consider the emotional impact of the emergency on the parent's judgement. You can usually resolve the situation with patience and calm persuasion. You may also need the help of others, such as ALS personnel, medical control, or law enforcement. - When you are not able to persuade the patient, guardian, or parent to proceed with treatment, you must obtain the signature of the individual who is refusing treatment in an official release form that acknowledges refusal. Document any assessment findings, the emergency care that you provided, your efforts to obtain consent, your consultation with medical control, and the responses to your efforts. You should also obtain a signature from a witness to the refusal. Make every effort to have a responsible person, such as a police officer, serve as a witness to these events. Retain the documents with your records -they will be important in the event a legal claim is filed later. If the patient refuses to sign a release form, inform medical control and thoroughly document the situation and the refusal. In some cases, parents who have refused medical care for a child have been charged with child neglect. You might be called as a witness in such cases and you must be sure that all documentation is thorough and accurate.

In which of the following situations does a legal duty to act clearly exist?

A call is received 15 minutes prior to shift change.

In cases when patients have a MedicAlert bracelet, the EMS provider can obtain patient history information from _____.

A foundation

Which of the following general statements regarding consent is correct?

A patient can consent to transport but can legally refuse to be treated.

EMTs must be familiar with the legal requirements that define their obligations to report a variety of special situations to the proper authorities. Which one of the following would NOT be considered a reportable situation?

A patient who admits to you he committed a traffic violation

Define consent and how it relates to decision making.

A person receiving care must give permission, or consent, for treatment. 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. The right of a patient to make decisions concerning his or her own health is known as patient autonomy. The terms decision making capacity and competence are often used interchangeably but there is a distinction: competence is generally regarded as a legal term and determinations regarding competence are typically made by a court of law, whereas decision making capacity is the term more commonly used in health care to determine whether or not a patient is capable of making health care decisions.

How would you define ethics?

A philosophy of right and wrong, of moral duties, and of ideal professional behavior.

To help protect patients, EMS agencies are required to have _____.

A privacy officer to answer questions

The EMT has a legal duty to act if he or she is:

A volunteer, is on duty, and is dispatched on a call.

An advance directive is:

A written document that specifies the care you should provide if the patient is unable to make decisions.

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.

Abandonment

When evaluating a noncritical patient in the field, you receive a call from dispatch regarding a serious four-car accident. You inform the patient you are treating to have someone take him to his doctor to get checked out before leaving to attend to the more seriously injured people. This is an example of what?

Abandonment

Able to make rational decisions about personal well-being.

Competent

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

Abuse of Children, Older People, and Others - Most states have a reporting obligation for certain people, ranging from physicians to any person. - Such statutes frequently grant immunity from liability for libel, slander, or defamation of character to the individual who is obligated to report, even if the reports are subsequently shown to be unfounded, as long as the reports were made in good faith. Injury During the Commission of a Felony - Many stages have laws requiring the reporting of any injury that is likely to have occurred during the commission of a crime, such as gunshot wounds, knife wounds, or poisonings. Drug-Related Injuries - In some instances, drug-related injuries must be reported. These requirements may affect how you approach documenting the care of a patient. - The US Supreme Court has held that drug addiction, in contrast to drug possession or sale, is an illness and not a crime. An injury as a result of a drug overdose, therefore, may not be within the definition of an injury resulting from a crime. - Some states, by statute, specifically establish confidentiality and excuse certain specified people from reporting drug cases, either to a governmental agency or to a minor's parents, if, in the opinion of those people, withholding reporting is necessary for the proper treatment of the patient. Childbirth - Most states require that anyone who attends at a live birth in any place other than a licensed medical facility report the birth. Other Reporting Requirements - Other reporting requirements may include attempted suicides, dog bites, certain communicable diseases, assaults, domestic violence, and sexual assault or rape. - Most EMS agencies require that all exposures to infectious diseases be reported. You may be asked to transport certain patients in restraints, which may also need to be reported. Each of these situations can present significant legal problems. - Not only do the events that need to be reported vary significantly from state to state but so do the methods and procedures by which such reporting must take place. - Failure to report may result in disciplinary action, suspension of your privileges to practice as an EMT, a fine, or even criminal prosecution. Scene of a Crime - If there is evidence at an emergency scene that a crime may have been committed, you must notify the dispatcher immediately so that law enforcement authorities can respond. - At times, you may have to transport the patient to the hospital before law enforcement arrives. 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. When a sexual assault is suspected, try to persuade the victim not to shower or clean himself or herself. You should confer periodically with local authorities and be aware of their wishes regarding actions you should take at the scene of the crime. The Deceased - If a victim is clearly dead and the scene of the emergency may be where a crime was committed, do not move or disturb the scene.

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.

Advance directive

A 57-year-old man fell down the stairs at his home and was badly injured. You arrive on the scene, the man allows you to conduct a brief assessment, and then he insists he is okay and does not need treatment. Before leaving, what should you do?

Advise the patient to contact his physician as soon as possible, ask the patient to sign a refusal of treatment form, encourage treatment again and remind him to call 9-1-1 if he changes his mind.

Which of the following is an example of abandonment?

An Emergency Medical Responder is transferred patient care from an Advanced EMT

If you choose to intervene while off duty, you must continue to provide competent care until which of the following happens?

An equal or higher medical authority assumes care of the patient

Good Samaritan laws are designed to protect:

An individual who voluntarily gives emergency medical care in good faith and within the boundaries of his or her training

Because of the U.S. Supreme Court's opinion on the matter, which of the following instances may not have to be reported?

An injury resulting from a drug overdose

The manner in which principles of ethics are incorporated into professional conduct.

Applied ethics

During your monthly internal quality improvement (QI) meeting, you review several patient care reports (PCRs) with the staff of your EMS system. You identify the patient's name, age, and sex, and then discuss the treatment that was provided by the EMTs in the field. By taking this approach to the QI process, you:

Are in violation of HIPAA because you did not remove the PHI from the PCR beforehand.

In which of the following situations would the EMT find himself or herself in court being sued by a plaintiff seeking a monetary judgement?

As a defendant in a civil lawsuit

Unlawfully placing a patient in fear of bodily harm.

Assault

You are treating a patient with an apparent emotional crisis. After the patient refuses treatment, you tell him that you will call the police and have him restrained if he does not give you consent. Your actions in this case are an example of:

Assault

Disclosure of what kind of information may result in liability for breach of confidentiality?

Assessment findings shared with medical staff

When there is evidence at an emergency scene that a crime may have been committed, you should:

Avoid cutting through holes in clothing that were caused by weapons, avoid leaving footprints in the dirt or grass, notify the dispatcher immediately

Unlawfully touching a patient or providing emergency care without consent.

Battery

You respond to the home of a 59-year-old man who is unconscious; has slow, shallow breathing; and has a weak pulse. The family states that the patient has terminal brain cancer and does not wish to be resuscitated. They further state that there is a DNR order for this patient, but they are unable to locate it. You should:

Begin treatment and contact medical control as needed.

The study of ethics related to issues that arise in health care is called:

Bioethics

The study of ethics related to issues that arise in health care.

Bioethics

Disclosure of information without proper authorization.

Breach of confidentiality

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.

Compensatory damages

You are called to attend to an elderly patient with an extensive medical history who is now in cardiac arrest. The patient's family tells you that the patient has a DNR order. There is no paperwork available but the patient does have a MedicAlert bracelet indicating Do Not Resuscitate. You should:

Confirm the patient identity and then confirm the DNR by calling the MedicAlert foundation number on the bracelet.

In the context of EMS, permission to render care.

Consent

You are caring for a patient with pancreatic cancer. The patient is emaciated and only responds to loud verbal stimulus with the occasional moan. He offers no other response. The family tells you that there is no DNR but they do provide you with a Physician Order for Life Sustaining Treatment (POLST), which provides medical orders and is signed by the patient's physician. As you review the documentation, your partner reports that the patient has stopped breathing and has no carotid pulse. You should:

Contact medical control for guidance

An 8-year-old boy was struck by a car, is unconscious, and is bleeding from the mouth. As you begin to provide care, a police officer tells you that he is unable to contact the child's parents. You should:

Continue to treat the child and transport as soon as possible.

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.

Contributory negligence

You belong to a small volunteer EMS company and are treating a patient with chest pain, and you feel 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 indicates that the patient has an allergy to aspirin. The patient later sues you. Which of the following is your best defense strategy?

Contributory negligence

An established process to determine the qualifications necessary to be allowed to practice a particular profession, or to function as an organization.

Credentialing

What is defined as an established process to determine the qualifications necessary to be allowed to practice a particular profession, or to function as an organization?

Credentialing

Once your ambulance is dispatched to an emergency, you have an obligation to respond. What is this called?

Duty to act

Discuss the importance of do not resuscitate (DNR) orders and local protocols as they relate to the EMS environment.

DNR orders give you permission not to attempt resuscitation. Laws differ from state to state; however, to be valid, DNR orders must meet the following requirements: - Clear statement of the patient's medical problem(s) - Signature of the patient or legal guardian - Signature of one or more physicians or other licensed health care providers - In some states, DNR orders contain an expiration date. DNR orders with expiration dates must be dated in the preceding 12 months to be valid. Remember, DNR does not mean "do not treat." Even in the presence of a DNR order, you are still obligated to provide supportive measures (oxygen, pain relief, and comfort) to a patient who is not in cardiac arrest. Specific guidelines vary from state to state, but the following four statements may be considered general guidelines: 1. Patients have the right to refuse treatment, including resuscitative efforts, provided that they are able to communicate their wishes. 2. A written order from a physician is required for DNR orders to be valid in a health care facility. 3. You should periodically review state and local protocols and legislation regarding advance directives. 4. When you are in doubt or the written orders are not present, you have an obligation to resuscitate. Local Protocols Acceptable DNR orders - Maryland MOLST Form or Bracelet (sending facility must provide paper copy to EMS prior to patient transport) - Maryland EMS/DNR Form or Bracelet (there is no expiration or older versions of DNR forms) - Medic Alert DNR bracelet or Necklace - Out-of-state EMS/DNR Form - Oral DNR Order from EMS System Medical Consultation - Oral DNR order from other on-site physician, physician assistant, or nurse practitioner Unacceptable DNR orders - Advanced directives (without a MOLST or DNR Order) or other oral or written requests shall not be honored by EMS without EMS System Medical Consulation

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

Decision-making capacity

Putrefaction is defined as:

Decompensation of the body's tissues.

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

Defamation

An obvious sign of death caused by discoloration of the body from pooling of the blood to the lower parts of the body is called what?

Dependent lividity

Blood settling to the lowest point of the body, causing discoloration of the skin; a definitive sign of death.

Dependent lividity

Oral questions asked of parties and witnesses under oath.

Depositions

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, which will assist in negotiating a possible settlement or in preparing for trial. This phase includes depositions, interrogatories, and demands for production of records.

Discovery

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

Do not resuscitate order (DNR)

Where would you MOST likely find information regarding a patient's wishes to be an organ donor?

Driver's license

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.

Durable power of attorney for health care

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

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

Duty to act

Describe the EMT's legal duty to act.

Duty to act is an individual's responsibility to provide patient care. A bystander is under no obligation to assist a stranger in distress and therefore has no duty to act. 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 Once your ambulance responds to a call or treatment is begun, you have a legal duty to act. In most cases, if you are off duty and come upon a crash, you are not legally obligated to stop and assist patients. There may be some circumstances where this is not true, and you should be familiar with the laws and policies that apply in your service area. If you choose to intervene while off duty, you must continue to provide competent care until an equal or higher medical authority assumes care of the patient.

Which of the following components are needed to prove negligence?

Duty to act, breach of duty, injury/damages, and causation

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

Emancipated minor

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

Emergency

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.

Emergency doctrine

Immediate care or treatment.

Emergency medical care

Which of the following would NOT be a circumstance that many states would consider for emancipation of a minor?

Employment

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

Encourage him to call 9-1-1 again if his condition worsens.

The philosophy of right and wrong, of moral duties, and of ideal professional behavior.

Ethics

Define ethics and morality and their implications for the EMT.

Ethics is the philosophy of right and wrong, of moral duties, and of ideal professional behavior. Morality is a code of conduct that can be defined by society, religion, or a person, affecting character and conscience. - Ethical issues are present in nearly every EMS incident. As an EMT, you will be expected to conduct yourself in a manner that is consistent with the standards of your profession and to keep the best interests of your patients at the forefront of your conduct and decision making. - Misconduct should be promptly reported to the appropriate chain of command. Similarly, you are obligated to report medical errors you make or witness to the medical director or another appropriate person as soon as possible. - As any group of professionals should, EMS providers should establish their own ethical standards and police the ethical behavior of their members. Ethical Decision Making Checklist (Check Yes or No) - Is the decision in the best interests of the patient? - Is the decision based on logic and reason rather than emotion? - Does the decision protect the patient's rights? - Would you agree to the same decision if you were the patient? - Would you make the same decision again in similar circumstances? - Can you defend this decision to others? In most cases that you will encounter as an EMT, there will be a rule, a law, or a policy that will guide your decision making and your actions. Your professional ethics trump personal morals while on duty. Absolute honesty in reporting is essential. You must provide a complete account of the events and the details of all patient care and professional duties.

When performing his or her duties, the EMT is generally expected to:

Exercise reasonable care and act prudently

Compare expressed consent, implied consent, and involuntary consent.

Expressed Consent - Expressed consent (or actual consent) is the type of consent given when the patient verbally or otherwise acknowledges that he or she wants you to provide care or transport. - Expressed consent may be nonverbal. For example, if you ask a patient if you can check his or her blood pressure and the patient extends an arm to you, the patient is expressing consent nonverbally. - To be valid, the consent the patient provides must be informed consent, which means that you explained the nature of the treatment being offered, along with the potential risks, benefits, and alternatives to treatment, as well as potential consequences of refusing treatment, and the patient has given consent. Implied Consent - 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. - Patients who are intoxicated by drugs or alcohol, mentally impaired, or suffering from certain conditions such as a head injury might be included in this category. - Implied consent applies only when a serious medical condition exists and should never be used unless there is a threat to life or limb. For this reason, the principle of implied consent is known as the emergency doctrine. - In most instances, the law allows a spouse, a close relative, or next of kin to give consent for an injured person who is unable to do so, and you should make every effort to obtain consent from an available relative before treating based on implied consent; however, treatment should never be delayed when the patient has imminently life-threatening injuries. Involuntary Consent - 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. In many cases, however, such permission will not be readily available. - Under certain conditions, law enforcement and prison officials are legally permitted to give consent for any individual who is incarcerated or has been placed under arrest. However, a prisoner who is conscious and capable of making decisions does not necessarily surrender the right to make medical decisions and may refuse care. Know the provisions in your area and involve online medical control in the process.

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

Expressed consent

Which type of consent is involved when a 39-year-old mentally competent female with a severe headache asks you to take her to the hospital?

Expressed consent

You arrive at the scene of a call to find an elderly man complaining of chest pain. You introduce yourself and ask permission to examine him. He nods and extends his arm. Which type of consent is this?

Expressed consent

A patient rescinds consent during transport and demands to be let out of the ambulance. If you refuse, you could be accused of:

False imprisonment

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

False imprisonment

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

The act of physically preventing an individual from initiating any physical action.

Forcible restraint

Describe local EMS system protocols for using forcible restraint.

Forcible restraint is sometimes necessary when you are confronted with a patient who is in need of medical treatment and transportation but is combative and presents a significant physical risk of danger to himself, rescuers, or others. Physically preventing such people from initiating any physical action is legally permissible and may be required before emergency care can be rendered. Typically, you should consult medical control for authorization to restrain or contact law enforcement personnel who have the authority to restrain people. In some states, only a police officer may forcibly restrain an individual. Your service should have clearly defined protocols to deal with situations involving restraint. It is important to remember that if the patient is conscious and the situation is not urgent, consent is required. After restraints are applied, they should not be removed en route unless they pose a risk to the patient, even if the patient promises to behave. It is essential you protect the patient's airway and monitor the patient's respiratory status while restrained to avoid asphyxia, aspiration, and other complications. Local Physical Restraint Guidelines: 1) Use the minimum restraint necessary to accomplish necessary patient care and ensure safe transportation; soft restraints may be sufficient in some cases. If law enforcement or additional personnel are needed, call for assistance prior to attempting restraint procedures. 2) Avoid placing restraints in such a way as to preclude evaluation of the patient's medical status (airway, breathing, and circulation). Patient positioning should be modified when restraining patients with limited mobility, previous injury, or preexisting conditions. 3) Patients shall not be restrained in a prone, hobbled, or "hog-tied" position. 4) Once restraints have been placed, do not remove them until you arrive at the hospital unless there is a complication from their use. If possible, take extra personnel during transport to hospital to deal with potential complications.

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.

Good Samaritan Laws

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

Governmental immunity

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

Gross negligence

What term is defined as conduct that constitutes a willful or reckless disregard for a duty or standard care?

Gross negligence

You and your partner arrive at the scene of a major motor vehicle crash. The driver, a young male, is severely trapped in his car. He has an open head injury and a massive facial trauma. He is unresponsive, is not breathing, and does not have a palpable carotid pulse. You should:

Have your partner check for a pulse to confirm that the patient is deceased.

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.

Health care directive

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.

Health care proxy

Describe the physical, presumptive, and definitive signs of death.

In many states, death is defined as the absence of circulatory and respiratory function. Many states have also adopted "brain death" provisions; these provisions refer to irreversible cessation of all functions of the brain and brain stem. In cases of hypothermia, the patient should not be considered dead until he or she is warm and dead. When the patient's condition is unclear, or if you are unsure if you should initiate care, it is best to begin CPR immediately and contact medical control for guidance. Presumptive Signs of Death Most medicolegal authorities will consider the presumptive signs of death that are listed below to be adequate. These signs would not be adequate in cases of sudden death due to hypothermia, acute poisoning, or cardiac arrest. Usually, in these cases, some combination of the signs is needed to declare death, not just one of them alone. - Unresponsiveness to painful stimuli - Lack of a carotid pulse or heartbeat - 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 Definitive or conclusive signs of death that are obvious and clear to even nonmedical people include the following: - 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 body muscles caused by chemical changes within muscle tissue. It develops first in the face and jaw, gradually extending downward until the body is in full rigor. The rate of onset is affected by the body's ability to lose heat to its surroundings. The rate of heat loss in a thin body is faster than in a fat body. A body on a tile floor has faster heat loss than a body wrapped up in a blanket in a bed. Rigor mortis occurs sometime between 2 and 12 hours after death. - Putrefaction (decomposition of body tissues). Depending on temperature conditions, this occurs sometime between 40 and 96 hours after death.

Permission for treatment given by a competent patient after the potential risks, benefits, and alternatives to treatment have been explained.

Informed consent

Which of the following is NOT a factor used in the determination of negligence?

Intent

Written questions that the defense and plaintiff send to one another.

Interrogatories

The EMT's scope of practice within his or her local response area is defined by the:

Medical director

Relating to medical jurisprudence (law) or forensic medicine.

Medicolegal

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

Morality

Which of the following describes a code of conduct that can be defined by society, religion, or a person, affecting character and conscience?

Morality

Failure of the EMT to provide the same care as another EMT with the same training is called:

Negligence

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

Negligence

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

Negligence Negligence is the failure to provide the same care that a person with similar training would provide in the same or a similar situation. Determination of negligence is based on the following four factors: 1. Duty. The EMT has an obligation to provide care and to do so in a manner that is consistent with the standard of care established by training and local protocols. 2. Breach of duty. There is a breach of duty when the EMT does not act within an expected and reasonable standard of care. 3. Damages. There are damages when a patient is physically or psychologically harmed in some noticeable way. 4. Causation. There must be a reasonable cause-and-effect relationship between the breach of duty and the damages suffered by the patient. If an EMT has a duty and abuses it, thereby causing harm to another individual, the EMT, the agency, and/or the medical director may be sued for negligence. This is often referred to as proximate causation. - All four elements must be present for the legal doctrine of negligence to apply and for a plaintiff to prevail in a lawsuit against an EMS system or provider. It is also possible for an EMT or an EMS system to be held liable even if the plaintiff is unable to clearly demonstrate how an injury occurred, under the theory of res ipsa loquitor. An EMT could be held liable under this theory if it can be showed that an injury occurred, that the cause of the injury was in the control of the EMT, and that such injuries generally do not occur unless there is negligence. - In rare cases, the plaintiff may be able to establish liability by using the theory of negligence per se. This is 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. - All forms of negligence come under the general category known as torts. Torts are simply defined as civil wrongs. Abandonment - Abandonment is the 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. Once care is started, you have assumed a duty that must not stop until an equally competent EMS provider assumes responsibility. - A part of your obligation as an EMT is to provide hospital personnel with a report of your assessment findings, the care you provided, and any changes in patient status that occurred during transport to the hospital. The failure to do so could result in a delay in treatment or a misdiagnosis. In such a case, a claim for abandonment might be filed against the EMT who failed to provide the report. It is always a good idea for you to obtain a signature on your PCR from the person accepting transfer of care at the hospital. This will help protect you from accusations of abandonment. Assault and Battery and Kidnapping - Assault is defined as unlawfully placing a person in fear of immediate bodily harm. Threatening to restrain a patient who does not want to be transported could be considered assault. - 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. In theory, this might include a situation where a patient is transported against his or her will. Criminal charges are almost unheard of in EMS because the EMT is almost always acting in a good faith effort to provide care to the patient. - It is far more likely that the EMT could be the target of a civil lawsuit for false imprisonment. This is defined as the unauthorized confinement of a person that lasts for an appreciable period of time. Consider a patient who rescinds consent during transport and demands to be let out of the ambulance. If you refuse, you may be accused of false imprisonment.

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.

Negligence per se

How often will an EMT be held to the same standard of care as a physician?

Never

Which of the following is only a presumptive sign of death?

No systolic blood pressure

Maintaining the chain of evidence at the scene of a crime should include:

Not cutting through holes in clothing that were caused by weapons.

Physical signs of death can be presumptive or definitive. Which of the following BEST describes the definitive signs of death?

Obvious mortal damage (decapitation) and/or dependent lividity and Rigor mortis and/or putrefaction (decomposition)

Which of the following BEST describes the definition of scope of practice?

Outlines the care you are legally able to provide for the patient

An EMT must give _____ to the possible donor or the organs will be damaged and become useless.

Oxygen

In the event that a patient has a DNR order, which of the following supportive measures (if any) are you allowed to provide?

Oxygen, pain relief, and comfort

Decomposition of body tissues; a definitive sign of death.

Putrefaction

Describe the relationship between patient communications, confidentiality, and the Health Insurance Portability and Accountability Act (HIPAA).

Patient Communications and Confidentiality - Communication between you and the patient is considered confidential and generally cannot be disclosed without permission from a parent or a court order. Confidential information includes the patient history, assessment findings, and treatment provided. HIPAA - The aim of this section of the act is to strengthen laws for the protection of the privacy of health care information and to safeguard patient confidentiality. It provides guidance on what types of information is protected, the responsibility of health care providers regarding that protection, and the penalties for breaching that protection. - HIPAA considers all patient information that you obtain in the course of providing medical treatment to a patient to be protected health information (PIH). This includes not only medical information, but also any information that can be used to identify the patient. - PIH may be disclosed for purposes of treatment, payment, or operations. This means you are permitted to report your assessment findings and treatment to other health care providers directly involved in the care of the patient. - In most situations, except for treatment purposes, only the minimum amount of information necessary should be released.

The right of a patient to make decisions concerning his or her health is called what?

Patient autonomy

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

Patient autonomy

HIPAA considers all patient information that you obtain in the course of providing medical treatment to a patient to be _____.

Protected Health Information

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.

Protected health information (PHI)

What aspect of the Health Insurance Portability and Accountability Act (HIPAA) MOST affects EMS personnel?

Protecting patient privacy

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.

Proximate causation

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

Punitive damages

A claim of abandonment can be filed against an EMT if he or she fails to do which of the following when dropping off the patient at the hospital?

Report the assessment findings, report any changes in patient status, report the care provided to the patient.

When treatment is refused, you must assess the person's ability to make an informed decision. Which of the following should you NOT do?

Request law enforcement assistance.

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

Res ipsa loquitor

When an EMT is in doubt of DNR orders or the written orders are not present, what should she/he do?

Resuscitate

Stiffening of the body muscles; a definitive sign of death.

Rigor mortis

Discuss the scope of practice and standards of care.

Scope of Practice - 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 further defines the scope of practice by developing protocols and standing orders. Standard of Care - The manner in which you must act or behave is called a standard of care. - Standard of care is established in many ways, among them local customs, statutes, ordinances, protocols, medical literature, textbooks, administrative regulations, and case law. In addition, professional or institutional standards have a bearing on determining the adequacy of your conduct. Standards Imposed by Local Custom - The standard of care is how a reasonably prudent person with similar training and experience would act under similar circumstances, with similar equipment, and in the same or similar place. As an EMT, you will not be held to the same standard of care as physicians or other more highly trained professionals. In addition, your conduct must be judged in the light of the given emergency situation, taking into consideration the following factors: - Any issues concerning the safety of the patient or rescuer - General confusion at the scene of the emergency - The needs of other patients - The type of equipment available Prevailing customs within a community are important elements in determining the standard of emergency care within that community. This means the accepted standard of care can change from one community to another. Examples of prevailing customs include how hospital destinations are selected, when EMS helicopters are used, and protocols for cervical spine immobilization. Standards Imposed by Law - In addition to local customs, standards of emergency medical care may be imposed by statutes, ordinances, administrative regulation, or case law. Professional or Institutional Standards - In addition to standards imposed by law, professional or institutional standards may be admitted as evidence in determining the adequacy of an EMT's conduct. - Professional standards include recommendations published by organizations and societies that are involved in emergency medical care. - Institutional standards include specific rules and procedures of the EMS system, ambulance service, or organization to which you are affiliated. You must be familiar with the standards of your organization If you are involved in formulating standards for a particular agency, they should be reasonable and realistic so that they do not impose an unreasonable burden on EMTs. Ordinary care is a minimum standard of care. If you act reasonably, according to the accepted standard, the risk of a civil lawsuit is small. If you apply the standard practices you have been trained to use, you can likely avoid liability. Standards Imposed by Textbooks - Since virtually all EMS textbooks follow standards established by the National Highway Transportation Safety Administration (NHTSA), these textbooks are often recognized as contributing to the standard of care that is followed by EMTs. Standards Imposed by States Medical Practices Act - In some states, EMS personnel are exempt from the licensure requirements of the Medical Practices Act because an EMT is regarded as a nonmedical professional. - As an EMT you must be aware of the standards established by legislation in your state so you can be sure to provide care that is consistent with those standards. Certification and Licensure - Some states provide certification, licensure, or credentialing of people who perform emergency medical care.

Most commonly defined by state law; outlines the care that the EMT is able to provide for the patient.

Scope of practice

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

Slander

Sharing patient stories with relatives and friends could result in a legal claim of:

Slander

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.

Standard of care

The time within a case must be commenced.

Statute of limitations

The conduct of an EMT is judged in the light of all of the following, EXCEPT:

The EMT's level of training

What is the EMT's priority when dealing with an organ donor?

Try to save the patient's life.

Standard of care can be defined as _____.

The manner in which you must act or behave.

In which of the following circumstances can the EMT legally release confidential patient information?

The patient is competent and signs a release form.

Which information obtained during an EMT's interaction with a patient is considered confidential?

The patient's history, assessment findings, treatment provided.

Credentialing refers to:

The process by which the qualifications to practice are determined.

A wrongful act that gives rise to a civil lawsuit.

Tort

You arrive at the scene of a motor vehicle-versus-pedestrian accident. The patient, a 13-year-old male, is unconscious and has multiple injuries. As you are treating the child, a law enforcement officer advises you that the child's parents will be at the scene in approximately 15 minutes. What should you do?

Transport the child immediately and have the parents meet you at the hospital.

When a patient is combative and poses a risk to the rescuer, it is advisable to:

Wait for law enforcement to arrive on scene before attempting treatment.

When is forcible restraint permitted?

When the patient poses a significant threat to self or others.

After state law, which medical professional further defines your scope of practice?

Your medical director

Which of the following statements about records and reports is FALSE?

Your patient care report does not become a part of the patient's hospital record because your treatment was provided outside the hospital.

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

in loco parentis