DMACC EMT Chapter 3

PREHOSPITALPREHOSPITAL
EMERGENCY CAREEMERGENCY CARE
CHAPTER
Copyright © 2014, 2010, 2008 by Pearson Education, Inc.
All Rights Reserved
Prehospital Emergency Care, 10th
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TENTH EDITION
Medical, Legal, and
Ethical Issues
3

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Learning ReadinessLearning Readiness
• EMS Education Standards, text p. 39

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ObjectivesObjectives
• Please refer to page 39 of your text to
view the objectives for this chapter.

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Key TermsKey Terms
• Please refer to page 40 of your text to
view the key terms for this chapter.

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Setting the StageSetting the Stage
• Overview of Lesson Topics
 Scope of practice
 Issues of consent and refusal
 Negligence and intentional torts
 HIPAA and EMTALA
 Other legal situations

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Case Study IntroductionCase Study Introduction
EMTs Phil Baker and Caitlyn O'Shea have
responded to an alley behind a strip mall
for an unresponsive person. Police are on
the scene and have been able to get a
response from the patient, who is now
sitting up. The patient, who is disheveled
and smells of alcohol and urine, shouts,
"I'm not going to the hospital. Get out of
here!"

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Case StudyCase Study
• What are the EMTs' legal obligations in
this situation?
• What ethical obligations do the EMTs
have?
• What information should the EMTs
attempt to obtain?

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IntroductionIntroduction
• Every EMS call involves legal and
ethical decision making.
• Most cases are clear.
• In some cases EMTs must weigh
complex information to act in the
patient's best interests.

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Scope of PracticeScope of Practice
• Scope of practice
 The actions and care that EMTs are
legally allowed to perform by the state
in which they work
 Establishes boundaries among
professionals
continued on next slide

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• Sources used to define scope of
practice
 National EMS Scope of Practice Model
 National EMS Education Standards
 State laws, regulations, policies

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• Scope of practice is not a practice
guideline or protocol.
• Scope of practice does not define the
standard of care.

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• Standard of care
 The care that is expected to be provided
by an EMT
 Defined by what a reasonably prudent
person with similar training would do in
the same situation

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 Two principles
• Did the EMT provide the right
assessment and care?
• Did the EMT perform the assessment and
care properly?

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 May be determined by:
• EMT textbooks
• The care that would be expected by other
EMTs
• Local and state protocols
• National EMS Education Standards
• The EMS system's operating policies and
procedures

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• Duty to act is the legal obligation to
provide service.
 You have a duty to act while you are on
duty with your service.

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• Duty to act is the legal obligation to
provide service.
 When you are not on duty, you do not
have a duty to act in most states.
 When beginning care while off duty, you
create a duty to act and may not leave
until someone with the appropriate
expertise arrives.

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• Duty to act involves an obligation to
carry out all aspects of the EMT's
responsibilities.
 Patient advocacy and protection of
rights
 Maintaining proficiency in knowledge
and skills
 Ensuring equipment is available and in
working order

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• Good Samaritan laws
 Protect a person who is not being paid
for his services from liability for acts
performed in good faith except in cases
of gross negligence

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• Good Samaritan laws
 You must:
• Render care to the best of your ability.
• Work within the scope of practice and to
the standard of care.
• Act professionally.
 Professional liability insurance can help
protect you if you are sued.

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• Other legal protections
 Sovereign immunity is afforded in some
cases to government employees.
 Statutes of limitations restrict the
amount of time a person has to file a
lawsuit.
 Contributory negligence on the part of
the patient

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• Medical direction
 The legal right to function as an EMT is
contingent on approval by medical
direction.

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• With regard to medical direction, you
must do the following:
 Follow approved standing orders and
protocols
 Communicate with medical direction
when needed

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• With regard to medical direction, you
must do the following:
 Communicate clearly and completely;
follow orders given by medical direction
 Whenever there is a question about the
scope or direction of care, consult
medical direction

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• Ethics
 Branch of philosophy focused on the
study of morality
• Morals
 Concepts of right and wrong

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• EMT Code of Ethics
 Places welfare of the patient above all
else when providing medical care
 Ethical responsibilities include those
listed on the following slides.

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• Serve the needs of the patient with
respect for human dignity, without
regard to nationality, race, gender,
creed, or status.
• Maintain skill mastery.
• Keep abreast of changes in EMS that
affect patient care; uphold professional
standards.

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• Critically review performance, seeking
ways to improve; assume responsibility
for individual actions and judgment.
• Report with honesty; maintain
confidentiality.
• Work harmoniously with other
members of the health care team.

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• When legal, ethical, and moral
obligations are in conflict:
 Follow protocols.
 Contact medical direction.

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The EMTs approach the patient. "Hi,"
says Caitlyn. "My name is Caitlyn, and
I'm an EMT. We're here because
someone called to say you were
unconscious. How are you feeling?"
"Like I've got too many people not
minding their business, that's how I
feel!" says the patient. "Why don't you all
just go away and leave me alone?"

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• Should Caitlyn and Phil do as the
patient has requested, and leave him
alone?
• What is the legal basis for your answer?
• If you believe Caitlyn and Phil should
stay, what do you think they should do
next?

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Consent and RefusalConsent and Refusal
• Competent patients have the right to
accept or refuse emergency medical
care.
• You must obtain consent before
providing care.
• Informed consent
 The patient must be informed of the
care to be provided and its risks and
consequences.

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• Indicate to the patient that you would
like to perform an assessment, provide
emergency care, and transport him to a
hospital.
• Ensure the patient's understanding and
ask if he has questions.
• Obtain explicit permission before
proceeding.

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• Types of consent
 Informed
 Expressed
 Implied
 Involuntary

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 Informed consent
• The patient agrees to be treated after
being advised about the treatment and
its risks and consequences.
 Expressed consent
• The patient's verbal or nonverbal
confirmation that he agrees to treatment.

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 Implied consent
• Emergency doctrine
• Assumes that a patient who is
unresponsive or not competent to give
consent would consent to care if he were
able to

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 Consent to treat minors
• Consent must be obtained by parent,
legal guardian, or authorized caregiver.
• If the parent cannot be reached, implied
consent is used.
• Parental consent is not needed for
emancipated minors.

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 Involuntary consent
• Applies to mentally incompetent adults or
individuals in law enforcement custody
• Consent is obtained from a third party,
such as a legal guardian or law
enforcement officer.

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• Advance directive
 Based on patients' right to self-
determination
 Documents the wish of the chronically or
terminally ill patient not to be
resuscitated
 Legally allows the health care provider
to withhold resuscitation

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 Types
• Do not resuscitate (DNR) order
• Living will
• Physician's orders for life-sustaining
treatment (POLST)
• Health care durable power of attorney
(health care proxy)

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 Do not resuscitate order
• Legal document that governs only
resuscitation issues
 Living will
• Addresses broader health care issues,
including long-term use of life-support
equipment and feeding tubes

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 Durable power of attorney
• Designates a person who can legally
make health care decisions if the patient
is unable to do so
• Usually pertain to in-hospital and long-
term care

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 Physician orders for life-sustaining
treatment
• Applies to patients expected to live less
than one year
• Describes varying levels of treatment
desired by the patient in the event that
resuscitation is needed

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 Physician orders for life-sustaining
treatment
• Must be signed by a physician, contain
physician contact information, and list
the dates it is valid

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 DNR or POLST must contain specific
language; some states use a standard
form.
 The document must be present in order
to withhold resuscitation.
 DNRs generally allow comfort measures
to be provided.

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An Ohio EMS DNR identification form.

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An Ohio EMS DNR identification form, continued.

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DNR documents may also take alternative forms, as these examples from Ohio EMS show: a DNR wallet card.

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DNR documents may also take alternative forms, as these examples from Ohio EMS show: a DNR hospital
bracelet.

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• Advance directive issues
 Determining validity of the document
 Interpreting the orders
 Conflict between the DNR or POLST and
wishes of the family

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• How to proceed with advance directive
issues
 If in doubt, consider initiating immediate
treatment.
 Contact medical direction.
 Continue treatment until the issue is
resolved.

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• Refusing treatment
 Competency
• A patient has the right to refuse care,
even if it will result in death.
• For the patient to refuse, he must be
competent.

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 Competence means the ability to make
an informed decision.
• Alert and oriented
• Does not have altered mental status, is
not under the influence of drugs or
alcohol

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 The patient must be informed of and
fully understand the treatment and the
potential risks or consequences of
refusing treatment.
 The patient must sign the release form,
or if he refuses, attempt to have
someone witness the refusal.

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 Document what you told the patient
about treatment and risks of refusal.
 Document the patient's response.

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• Protecting yourself in a refusal situation
 Exhaust your attempts to persuade the
patient.
 Make sure the patient is competent.
 Consult medical direction according to
protocol, or if otherwise needed.
 Clearly document what you told the
patient and his response to it.

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• Protecting yourself in a refusal situation
 Encourage the patient to seek help if
problems continue or other problems
occur.
 If you are uncertain as to the patient's
competence, contact medical direction

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"I can understand how you might feel like
people are in your business right now," says
Caitlyn. "We are here to help, but before we
can decide what to do, I need to ask you a few
questions. What is your name?"
"Mike Blevins."
"Mr. Blevins, do you know where you are right
now?" asks Caitlyn, beginning the process of
determining the patient's decision-making
ability.

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What questions should Caitlyn ask to
help her decide whether the patient has
the capacity to make an important
decision, such as consenting to or
refusing medical care?

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NegligenceNegligence
• A breach of legal duty creates a
liability.

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• A breach of legal duty creates a
liability.
• Two types of liability
 Criminal
• The government brings charges against
the EMT.
• May result in fines or imprisonment

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• Two types of liability
 Civil
• The party who claims injury, the plaintiff,
files a lawsuit.
• The injury is a result of a wrongdoing,
called a tort.
• The lawsuit seeks monetary
compensation for damages.

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• Negligence is a tort in which:
 There was no intent to do harm
 But there was a breach of duty to act

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• Elements to prove negligence:
 The EMT had a duty to act.
 The EMT breached the duty to act.
 The patient suffered harm or injury.
 The injury was a result of the breach of
duty (proximate cause).

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• Associated legal principles
 Res ipsa loquitur
• "The thing speaks for itself."
• The inappropriate actions are obvious.
 Negligence per se
• The act is negligent simply because it
violates a statute or regulation.

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• Duty to act
 Legal obligation to respond and provide
emergency care
 Once the patient-provider relationship
has been established, the provider
cannot terminate it without consent of
the patient, or turning over patient care
to a qualified provider of equal or higher
training.

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• Breach of duty to act
 Occurs when the EMT's care deviates
from the standard of care
 Simple negligence occurs when an EMT
fails to perform care or makes a mistake
in treatment.
 Gross negligence occurs when there is
willful, wanton, or reckless action
beyond just carelessness.

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• Damages
 Real, demonstrable injuries that are
recognized by law
 Cannot be trivial or minor

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• Proximate cause
 It must be determined that the patient's
injury was a result of the EMT's actions.

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Intentional TortIntentional Tort
• An action knowingly committed by an
individual that is considered civilly
wrong
• Includes abandonment, assault,
battery, false imprisonment, and
defamation
• Differs in that negligence is a failure to
meet the standard of care, whereas an
intentional tort is knowingly committed

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• Abandonment
 Occurs when you stop treatment without
appropriate transfer of care
 You must transfer care with a report to
the health care provider accepting the
patient.
 The accepting provider must be trained
to your level or higher.

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EMTs transferring care to a flight crew for transport to a trauma center. You must always transfer care of the
patient to a professional of equal or better training to avoid charges of abandonment.

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• Assault
 Willful threat to inflict harm on a patient
 Can occur without actually touching the
patient

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• Battery
 Unlawfully touching a patient
 Without consent, touching a patient is
unlawful

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• False imprisonment or kidnapping
 Intentionally transporting a competent
patient without his consent
 Failing to allow a competent patient to
withdraw from treatment when he
desires to do so

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• Defamation
 Communicating information to others
that is damaging to a person's
character, reputation, or standing within
the community
• Slander is a spoken form of defamation.
• Libel is a written or mass-media
delivered form of defamation.

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Medical-Legal Terminology CheckMedical-Legal Terminology Check
• Match the term below to
the statement that best
describes it by clicking on
the text box of your
selected response.
Abandonment
A tort in which there was no intent to
cause harm.
cause harm.
Transporting a competent patient
against his will.
against his will.
A legal responsibility to do
something.
something.
Unlawfully touching a patient.Unlawfully touching a patient.
Terminating patient care without the
patient's agreement and without
transferring care to another provider.
Terminating patient care without the
patient's agreement and without
transferring care to another provider.

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selected response.
Battery
A tort in which there was no intent
to cause harm.
A tort in which there was no intent
to cause harm.
against his will.
against his will.
something.
something.
Unlawfully touching a patient.Unlawfully touching a patient.
Threatening a patient, verbally or
nonverbally, with harm.
Threatening a patient, verbally or
nonverbally, with harm.

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selected response.
Negligence
cause harm.
cause harm.
against his will.
against his will.
A legal responsibility to do something.A legal responsibility to do something.
Releasing confidential patient
information without his consent.
Releasing confidential patient
information without his consent.
Deliberately performing or omitting an
act that results in harm to a patient.
Deliberately performing or omitting an
act that results in harm to a patient.

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selected response.
Duty to act
cause harm.
cause harm.
Transporting a competent patient against
his will.
Transporting a competent patient against
his will.
A legal responsibility to do something.A legal responsibility to do something.
A written authorization to perform certain
care for patients who present with specific
complaints.
A written authorization to perform certain
care for patients who present with specific
complaints.
The skills and actions that an EMT is
legally allowed to and expected to perform.
The skills and actions that an EMT is
legally allowed to and expected to perform.

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selected response.
Defamation
Making statements about a person, orally or in
writing, that harm his reputation.
Making statements about a person, orally or in
writing, that harm his reputation.
Transporting a competent patient against his
will.
Transporting a competent patient against his
will.
Refusing to transport a patient who requests it.Refusing to transport a patient who requests it.
Releasing confidential information about a
patient without his consent.
Releasing confidential information about a
patient without his consent.
Treating a patient who is not competent to give
consent on the assumption that he would agree
to treatment if he was able.
Treating a patient who is not competent to give
consent on the assumption that he would agree
to treatment if he was able.

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ConfidentialityConfidentiality
• Do not speak to the press, your family,
friends, or the public about details of
the emergency care you provided to a
patient.
• Releasing confidential information
requires a written release form signed
by the patient or a legal guardian.

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• By law, you can release information if:
 Another health care provider needs to
know in order to continue medical care
 Mandatory reporting laws apply
 The police require information as part of
a potential criminal investigation
 A third-party billing form requires the
information
 You are subpoenaed

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• HIPAA and EMS
 You may discuss patient-specific
information only when there is a medical
necessity.
 You must receive training in your
agency's policies.
 Patients must be provided with privacy
policies.

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COBRA and EMTALACOBRA and EMTALA
• Consolidated Omnibus Budget
Reconciliation Act (COBRA)
• Emergency Medical Treatment and
Active Labor Act (EMTALA)
• Federal regulations that ensure access
to emergency health care regardless of
ability to pay

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• EMS becomes involved when patients
are being transferred from a hospital to
another medical facility.
• The patient must first be stabilized to
the best of the medical facility's ability.
• The ambulance crew performing the
transfer must be qualified and capable
of managing the patient and his
condition.

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• In an emergency transport do not make
a decision to transport to a specific
facility based on the patient's ability to
pay.
• Do not bypass a facility that is able to
treat the patient, unless directed to do
so by medical direction or protocol.
• Document the reason for bypassing the
facility.

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• For interfacility transfers
 Get a full report about the patient's
condition.
 Ensure that you are able to provide the
level of care necessary .
 Obtain the patient's informed consent
for the transfer.

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• For interfacility transfers
 Obtain written certification for the
transfer from the transferring physician.
 Know where you are going and take the
quickest possible route.

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Special SituationsSpecial Situations
• Organ donation
 Organs can be donated only if there is a
legal signed document giving
permission.
 A signed donor card is a legal
document; driver's license organ donor
status provides an intent to donate
organs.

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• Organ donation
 Treat a potential organ donor no
differently from any other patient.
 Patients who are about to die or who
have died within hours are potential
organ donors.
 Hospital staff and family make the
ultimate decision.

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• Organ donation
 Communicate with medical direction
regarding the possibility of organ
donation.
 Provide emergency care as you would
for any other patient.

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Recognizing Death in the FieldRecognizing Death in the Field
• Generally, if the patient is still warm
and does not exhibit any obvious signs
of death, begin resuscitation.
• There is an exception for patients with
hypothermia.

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• For patients with a DNR, assess for
presumptive signs of death.
 Absence of a pulse, breathing, and
breath sounds
 Complete unresponsiveness to any
stimuli
 No eye movement or pupil response
 Absence of a blood pressure
 No reflexes

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• Cases requiring investigation by the
coroner or medical examiner
 Homicide
 Suicide
 Violent death
 Crash-related death
 Unusual scene characteristics
 Sudden infant death syndrome (SIDS)
 Dead on arrival (in some locations)

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Crime ScenesCrime Scenes
• Your first concern upon approaching a
crime scene should be for your own
safety.
• Recognizing a possible crime scene
requires a high index of suspicion.
• Potential crime scenes require police
support.

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• Wait until the police declare that the
scene is safe.
• Even when the police declare the scene
safe it can still be potentially
dangerous.
• Once the scene is secure, your priority
is emergency care of the patient.

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• Avoid disturbing potential evidence.
 Take one way in and out.
 Touch only what you must; tell a police
officer if you move or touch anything.
 Move only what you must.
 Do not use a crime scene telephone.

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 In the absence of police permission,
move the patient only if he is in danger
or must be moved for you to provide
care.
 Observe and document carefully.
 Do not cut through holes in clothing.

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 Do not cut through any knot in a rope or
tie.
 Do not cover the patient with a sheet.
 If the crime is rape:
• Do not wash the patient or allow the
patient to wash.
• Ask the patient not to change clothing,
use the bathroom, or take anything by
mouth.

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Baby Safe Haven LawsBaby Safe Haven Laws
• Designed to prevent child abandonment
• Allow a parent to relinquish custody of
an unharmed infant to a proper
authority
• An EMS station may be a designated
safe haven.

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Lesson SummaryLesson Summary
• Emergency care involves medical, legal,
and ethical issues.
• Scope of practice identifies what care
can legally be performed.
• Standard of care identifies the accepted
level of care.

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• EMTs have a duty to act.
• Medical direction is required for medical
oversight of an EMS system.
• Consent applies in all patient care
situations.
• A competent adult can refuse care.

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• Four elements must be proven to
establish negligence.
• EMTs must maintain patient
confidentiality.
• HIPAA, COBRA, and EMTALA apply to
EMS.
• There are special considerations in
responding to crime scenes.

DMACC EMT Chapter 3

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