This document discusses several key legal aspects of disaster nursing including standards of care, informed consent, duty of care, negligence, documentation, confidentiality, and preservation of forensic evidence. It defines disaster and describes different types. It also covers constitutional amendments related to individual rights and liberty restrictions during disasters. Public health emergency powers and the disaster declaration process are outlined. Issues around volunteers, liability protection, and crisis standards of care are also summarized.

1. Disaster Preparedness: Legal Aspects
of Disaster Nursing
Presented By: Prof. Shikha
Shrivastava

2. • The three core of ethical issues
• Standards of care in Disaster
• Informed consent
• Duty of care
• Negligence
• Documentation
• Confidentiality
• Preservation of forensic evidence

3. DISASTER
Disaster is any occurrence that causes damage,
ecological disruption, loss of human life or
deterioration of health and health services on a
scale sufficient to warrant an extraordinary
response from outside the affected community
or area.
(WHO 1995)

4. TYPES
Natural
Man made
Mixed

6.  Constitutional Amendments: Constitution
provides individuals with the rights of due
process and equal protection under the law
- Individual Rights
- Individual liberty restrictions
Individual liberty may be restricted under the
following conditions,
Compelling interest (keep dangerous people
away from society; keep danger from
spreading) Well-targeted intervention

7.  This includes public health law and police
powers. Police powers enable a state to
protect public health, welfare, and morale,
and include public health emergency powers.

8.  Public health emergency powers include:
surveillance, reporting, epidemiological
investigation, power over property, voluntary
or mandatory vaccination, isolation,
treatment, social distancing (including
closure of schools, public buildings, and
public gathering places like shopping malls),
and evacuation.

9.  The process for disaster declaration starts
with the state. The declaration triggers public
health emergency powers. The state then can
request federal assistance, which can then be
provided by the Secretary of Health and
Human Services for a public health
emergency.

11.  The duty to treat extends from the social contact
between caregivers and society: The benefits of
professional status are accepted by fulfilling
known obligations.
 The duty to treat also derives from special
training that generates unique capabilities in
proximity of those in need and without other
sources of aid.
 The duty to treat includes nondiscrimination
based on those with disease, eg, a professional
cannot refuse care of infected patients.

12.  Individual casualties exist within a community of
casualties. Reciprocal social obligations ensure that
those providing care have reasonable provisions
against harm, such as PPE and liability protection,
and receive care themselves when injured in the
course of duty.
 Personal safety is essential so that caregivers do not
themselves become casualties, adding to the
casualty burden and reducing resources for care.
There is no absolute universal threshold for
treatment in the context of disaster, making “crisis
standards of care” a particularly salient topic.
 For example, police and firefighters have a 1-5%
lifetime risk of mortality on the job.

13.  Some states define volunteers as state employees
during disasters Some volunteers, as temporary
employees, may be eligible for benefits from
receiving institution. This is a state issue.
 Most workers’ compensation laws only cover
employees, but some states include volunteer
workers. In some states, volunteers are defined
as state employees during disaster. If temporarily
employed by an institution, some volunteers may
be eligible for benefits from the institution
benefiting from the volunteer.

14.  The Uniform Emergency Volunteer Health
Practitioner Act [UEVHPA]Medical Reserve
Corps Federal health care providers need
only be licensed in one state to perform
their official duties in any state. These
include providers in the uniformed services
and the Veteran’s Administration, and those
in federalized Disaster Medical Assistance
Teams.

15. • Federal health care providers Federalized
health care providers (DMAT)States regulate
licensure, and health care facilities and
payers regulate credentialing.

16. •Federalized providers Gaps in liability protection
Regardless of the situation, there is no immunity for
criminal liability (willful actions that cause harm).

17.  There can be civil immunity for liability,
varying by state: Mutual aid compacts
 Good Samaritan statutes State emergency
health powers statutes.
 UEVHPA Federalized providers have civil
immunity It is clear that gaps remain in liability
protection for responders.

18. The purpose of the UEVHPA was to develop a uniform and coordinated
approach to quickly deploy health practitioners to disaster areas. The
UEVHPA is triggered by the declaration of an emergency by an
authorized state or local official, is in effect for the duration of that
emergency, and applies to all licensed volunteer practitioners who
provide health or veterinary services.

19.  UEVHPA provides two alternative sections on
immunity from liability for states to consider.
 Alternative A “provides immunity from liability
for ordinary negligence to all volunteer health
practitioners and immunity from vicarious
liability to the entities engaged in deploying
and using them. ”
 Alternative B “provides immunity from liability
for ordinary negligence only to practitioners
who are nominally compensated in a manner
comparable to the federal Volunteer
Protection Act and defers to other state law
the question whether the entities deploying
and using them may be vicariously liable”

20.  Exceptions to protection from liability under
both alternatives include:
(1) willful misconduct or wanton, grossly
negligent, reckless, or criminal conduct;
(2) an intentional tort;
(3) breach of contract;
(4) a claim asserted by a host entity or by an entity
located in this or another state which employs
or uses the services of the practitioner.

21.  an act or omission relating to the operation
of a motor vehicle, vessel, aircraft, or other
vehicle. In addition, under the UEVHPA,
volunteer health practitioners who are
injured or die as a result of providing health
or veterinary services are deemed to be an
employee of the state for purposes of
receiving benefits under the workers’
compensation law.

22.  health professionals have opportunities and responsibilities
to be part of an effective disaster response. It has been said
that “every physician’s second specialty is public health.” In
practice, with regard to disaster planning and response, this
means that every health professional can and should play a
role, though that role will vary according to their skills and
interests.

23. • Quarantine: Quarantine involves separation or
restriction of movement of healthy people exposed
or potentially exposed
• Isolation: Isolation separates those known to be ill or
infected from the rest of the community
• Social distancing: Social distancing reduces exposure
risk by closing areas of communal gathering (eg,
schools, churches) and cancelling events
• Curfew: imposes a time limit on population activity
within a community as a way to minimize high-risk
behaviors
Restrictions on personal liberty in a public health
emergency include:

24.  Power rightfully exercised over any member of a
civilized community, against his will, to prevent
harm to others.
 Ethical dilemma eased if proposed restriction
prevents harm to others Philosopher John Stuart.
Mill defined the “harm principle” in the context of
restriction of liberty in this way:
“The only purpose for which power can be
rightfully exercise over any member of a civilized
community, against his will, is to prevent harm to
others”.
 The ethical dilemma posed by restriction is eased
if the restriction is effective for its intended
purpose.

25.  The effectiveness of any intervention to restrict
liberty depends on many factors, including the
degree to which individuals in the community are
willing to go along with the restriction.
 For example, social characteristics such as trust in
local public health authorities can make a mandatory
quarantine seem more like a voluntary activity, or
even an heroic action, for the affected group, and it
is likely to be effective. Conversely, if the affected
group does not trust the public health authority to
do what is right, then it is unlikely even a mandatory
quarantine will be fully effective.

26.  The waiver applies within the period of
emergency to the declared emergency area
and hospitals that have activated their
disaster plans for 72 hours.
 Two relevant regulations may be waived:
1. Emergency Medical Treatment and Active
Labor Act (EMTALA)Under normal
circumstances, requires screening of
patients to determine condition and
stabilization of patients prior to transfer or
discharge

27.  The Health Insurance Portability And Accountability
Act (HIPAA)privacy rule requirements that may be
waived: Requirements to obtain a patient's
agreement to speak with family members or
friends involved in the patient’s care

28.  When resources (such as vaccines) are scarce,
rationing is a method for assigning them by
priority. Goals of rationing include:
 Save most lives (higher risk)
 Save most life years
 Save most productive life years Women and
children
 First come, first served Market-based

29.  Standard of Care Perform to the highest
reasonable standard under given circumstances
Standard of care depends on context. Disaster
context is not normal routine Not possible to
attain routine standard without resources.
 A great deal of attention is given to the standard
of care in disaster situations.
 The reality is that both legally and ethically the
standard of care always, by definition, depends
on the context of that care. There cannot be a
single standard of care that will apply in every
context

30.  “crisis standards of care.” Key aspects of this
definition include substantial, not minimal;
necessary, not optional; justified, ethically as
well as legally; declared formally; sustained
differences, not fleeting; and specific new
powers and protections enables. Rationing is
necessary and inevitable--not a choice--for
health care providers under these conditions.

31. Successful implementation of crisis care to crisis
standards of care requires
1. Fairness: recognized as fair by all.
2. Equitable processes: transparent, consistent,
proportional, accountable.
3. Participatory engagement: in development and
promulgation pre-event, and in application post-
event.
4. Governed by rule of law with defined authority and
an appropriate legal environment. This provides
legal acknowledgement that the context exists for
crisis care.

32.  Expectant care has an ethical basis in settings of
severe injuries and resource shortage.
 The principles of non-malfeasance and justice
are prominent. Casualties (and patients) who are
absolutely unsalvageable require comfort care,
without expending resources for cure.
 Casualties with injuries greater resources
available may be relatively unsalvageable under
the circumstances.
 This may change as the casualties or resources
change.

33.  The intent of comfort care is just that,
comfort; thus, comfort care is not equivalent
to euthanasia. Society remains uncomfortable
with the notion of expectant. We like to
believe that no injured patient is
unsalvageable, and that no resource
limitations exist. These are false
assumptions.

34.  Ethical triage systems ensure the fair use of
limited resources to achieve the greatest
good for the greatest number, which includes
expectant comfort care, promoting
transparent, consistent decision making
based on situational awareness, and avoiding
adhoc decisions by individuals.

35. Needs to be:
• Knowledgeable
• Skillful
• Educated
• Professional
• Accountable

36. Uses:
– The ATS
– Physiological discriminators
– Local policies & protocols
Needs:
• Basic understanding of legal principles.

37. • Chaotic environment
• Undifferentiated patients
• Shear volume
• Stress
• Human factors
• Patient factors

39. The 5 elements:
1. Must be given voluntarily
2. Person need’s legal capacity
3. Should be informed
4. Must be specific
5. Cover what's actually being done

40. • Can mean you have to defend yourself against
battery charges!

41. “Once a patient presents , the triage nurse
enters into a health professional-patient
relationship”

42. Duty of Care
“The triage nurse shares responsibility on behalf
of the hospital to ensure patients receive
appropriate assessment of their treatment
needs.”

43. • An obligation recognised by law:
– Triage nurse is expected to provide same
level/degree of care
– Protect PT from foreseeable harm
– Provide reasonable standard of care

44. • Detaining PT’s against their will:
Needs to be:
– Risk to self
– Risk to community
• Principle of necessity under common law.
• Arrange senior clinician review

45. • Be of sound mind
• Over 16
• No drug or alcohol
• Have insight
• Understand risk
• Communicate

46. • Ensure capacity
• PT’s have the right to leave
• If concerned let them know
• Invite them back
• Measure of ED performance!

47. “Nurses have a responsibility to behave in a
reasonable manner”
“Breach from this responsible approach which
results in harm/injury constitutes negligence”

48. For negligence to be proven:
– Duty to meet standard of care
– Breach of the duty to meet standard of care
– Breach of duty which causes foreseeable harm
– Causing actual harm & injury
– Causing loss

49. • Date & time
• Name of triage nurse
• Chief complaint/presenting problem
• Relevant Ax findings
• Initial triage category
• Area allocated
• Tx initiated @ triage

50.  “Health professionals must maintain any
information that has been provided in-
 confidence to them.”

51. “ The triage nurse has responsibility to ensure
patient privacy.”

52. • Risk to self
• Risk to other community
Example:
– Child reports abuse!

53. • These patient have higher Morbidity &
mortality
• There giving us a second chance to
diagnose properly

55. • Documentation must be accurate
• Duty of care can be a gray area
• Know dept’s policy & protocols.