Chapter 3: Medical, Legal, and Ethical Issues

Describe local EMS system protocols for using forcible restraint

- forcible restraint is sometimes necessary when you are confronted with a combative patient - in some states only a Police officer may forcibly restrain a patient • 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 to treat the patient. - 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

Define consent and how it relates to decision making

Consent: - a person receiving care must give permission, or consent, for treatment - an adult who is conscious, rational, and capable of making informed decisions have a legal right to refuse care - The patient may consent to some care, and refuse other 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

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. • 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 - • Implied consent applies only when a serious medical condition exists and should never be used unless there is a threat to life or limb 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

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

-Involve online medical control & document this consultation - Document the following information in your patient care (your assessment, risks of treatment, description of the treatment, alternative treatments, possible consequences of refusal) - Assess the patient's ability to make an informed decision - do not endanger yourself to provide care, wait for law enforcement - before leaving the scene (encourage patient to call 911, advise patient to contact physician, ask patient to sign a refusal form) - Documentation should include assessment findings & all efforts to obtain consent - description of possible consequences refusing treatment & transport - have patient's signature witnessed by someone else

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

Abuse of children, older people, and others • All states have enacted laws to protect abused children. • Some have added other protected groups such as the older population and "at-risk" adults. • 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 are made in good faith Drug related injuries • In some instances, drug-related injuries must be reported. • 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 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 government 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 • Many states require that anyone who attends at a live birth in any place other than a licensed medical facility report the birth Crime scene • 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. • Be careful not to disturb the scene of the crime any more than absolutely necessary

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 similar situation 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 Assault: 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: ant to be transported could be considered assault. • Battery is unlawfully touching a person, including providing emergency care without consent. • Assault and battery can be either civil or criminal in nature Kidnapping: is the seizing, confining, abducting, or carrying away of a person by force. ◦ Criminal charges of kidnapping are almost unheard of in EMS because the EMT is almost always acting in a good faith effort to provide care to the patient.

Describe the physical, presumptive, and definitive signs of death

Physical: - • In many states, death is defined as the absence of circulatory and respiratory function. • Many states have also adopted "brain death" provisions Presumptive: - (IN table) - usually in these cases some combination of the signs is needed to declare death, not just one of them alone Definitive signs: - obvious and clear( such as decapitation) Dependent lividity: blood settling to the lowest point in the body causing discoloration Rigor mortis: the stiffening of body muscles caused by chemical changes within muscle tissue Putrefaction: decomposition of body tissues

Discuss the scope of practice and standards of care

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 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 and Institutional Standards: • 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 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. ◦ Some states have adopted legislation that establishes the scope of practice for EMS providers so they provide care that is consistent with those standards.

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

• A do not resuscitate (DNR) order is also known as a "do not attempt resuscitation" order. • An advance directive is a written document that specifies medical treatment for a competent patient, should he or she become unable to make decisions - DNR does not mean do not treat - dnr must gave patient's medical problems, signature of patient, signature of one or more physicians

Describe the roles and responsibilities of the EMT in the court

• As a witness in a civil case, you may be called to testify about the condition of the plaintiff when you arrived at the scene and about the treatment that you provided. • In a criminal case, you may be asked to describe a crime scene, the injuries that you found when you examined a crime victim, or to testify concerning any admissions or statements made to you by a criminal defendant. • Whenever you're subpoenaed to testify, notify the director of your service and legal counsel. • As a witness you should remain neutral during your testimony. • Review your run report prior to your court appearance. • As a defendant in either a civil or criminal proceeding, you will require the assistance of an attorney. • In a civil lawsuit, your service or its insurance company generally will provide you with legal counsel

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

• Confidential information includes the patient history, assessment findings, and treatment provided. • Disclosure of such information without proper authorization may result in liability for breach of confidentiality. • Patient information may be shared with third-party billing personnel • The Health Insurance Portability and Accountability Act of 1996 (HIPAA) strengthened laws for the protection of the privacy of health care information in order to safeguard patient confidentiality • HIPAA considers all patient information that you obtain in the course of providing medical treatment to a patient to be protected health information (PHI). • PHI may be disclosed for purposes of treatment, payment, or operations.

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. • In specific circumstances, a patient who is not successfully resuscitated may be a potential organ donor • 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. 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

Describe the EMT's legal duty to act

• Duty to act is an EMT's responsibility to provide patient care. • There may be a duty to act in certain instances, including: ◦ 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. ◦ 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

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. • Report misconduct to the appropriate chain of command • You are bound to follow all such policies, rules, and laws, even in those rare circumstances where your own personal sense of ethics might lead you to a different result

Recognize the importance of medical identification devices in treating the patient

• Many patients will carry medical identification and information, often in the form of a bracelet, necklace, key chain, or card that identifies patient history information. ◦ This may include a DNR order or information related to medications taken, allergies, diabetes, epilepsy, or some other serious condition. • Some patients wear medical bracelets with a USB flash drive. ◦ The information on the flash drive 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 child. • In every state, when a parent cannot be reached to provide consent, health care providers are allowed to give emergency care to a child. • Emancipated minors are people who, despite being under the legal age in a given state (in most cases the age is 18 years), can be legally treated as adults based on certain circumstances. • Many states consider minors to be emancipated if they are: ◦ Married ◦ Members of the armed services ◦ Parents ‣ A minor who is a parent may also give consent for his or her own child. ◦ Living away from and no longer relying on his or her parents for support