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  1. 1. LEGAL ASPECTS OF PRE-HOSPITAL CARE Presented by: Steven Jones, NREMT-P Clear Lake Emergency Medical Corps and Elizabeth Bradley, EMT-P Student College of the Mainland
  2. 2. Definitions <ul><li>Abandonment </li></ul><ul><ul><li>failure to provide care for the patient once it has been initiated </li></ul></ul><ul><li>Assault </li></ul><ul><ul><li>an action that places a person in immediate fear of bodily harm </li></ul></ul><ul><li>Battery </li></ul><ul><ul><li>touching another person without their consent </li></ul></ul><ul><li>Civil (tort) law </li></ul><ul><ul><li>deals with noncriminal matters such as contract disputes, medical malpractice, and conflicts between two parties. The parties sue each other </li></ul></ul>
  3. 3. Definitions <ul><li>Confidentiality </li></ul><ul><ul><li>privacy of all patient related information </li></ul></ul><ul><li>Consent </li></ul><ul><ul><li>granting permission to treat </li></ul></ul><ul><li>Criminal law </li></ul><ul><ul><li>deals with crime and punishment. The state sues an individual who is accused of committing a crime </li></ul></ul><ul><li>Emancipated Minor </li></ul><ul><ul><li>a minor (under 18 years) that is responsible for his/her own maintenance and support </li></ul></ul>
  4. 4. Definitions <ul><li>Expert Witness </li></ul><ul><ul><li>a witness that has special or extensive knowledge regarding the subject about which they are called to testify </li></ul></ul><ul><li>Expressed Consent </li></ul><ul><ul><li>when a competent, adult patient gives permission to be treated </li></ul></ul><ul><li>Implied Consent </li></ul><ul><ul><li>when a patient is unable to give expressed consent the law assumes that they would desire to have life-saving treatments rendered </li></ul></ul><ul><li>Lawsuit </li></ul><ul><ul><li>a legal action initiated by one party against another </li></ul></ul>
  5. 5. Definitions <ul><li>Libel </li></ul><ul><ul><li>injuring a person’s character or reputation by false or malicious writings </li></ul></ul><ul><li>Negligence </li></ul><ul><ul><li>failure to administer the same degree of care that a reasonable person would exercise under the same circumstances </li></ul></ul><ul><li>Rights </li></ul><ul><ul><li>liberties, allowed for under the law, for which each person is entitled </li></ul></ul>
  6. 6. Definitions <ul><li>Slander </li></ul><ul><ul><li>injuring a person’s character or reputation by false or malicious words </li></ul></ul><ul><li>Standard of Care </li></ul><ul><ul><li>what a reasonable and prudent person would do under similar circumstance </li></ul></ul>
  7. 7. Scope of Practice <ul><li>Scope of Practice </li></ul><ul><ul><li>outlines the care EMT’s are able to provide to the patient </li></ul></ul><ul><li>IN TEXAS . . . . . . </li></ul><ul><ul><li>There is no “defined” scope of practice </li></ul></ul>
  8. 8. Scope of Practice <ul><li>Established by Medical Director </li></ul><ul><ul><li>Medical Practice Act </li></ul></ul><ul><ul><ul><li>Allows Physicians to delegate procedures to EMS personnel </li></ul></ul></ul><ul><ul><li>Protocol </li></ul></ul><ul><ul><li>On-Line </li></ul></ul>
  9. 9. Standard of Care <ul><li>Local Custom </li></ul><ul><ul><li>Similar Training & Experience </li></ul></ul><ul><ul><li>Protocol </li></ul></ul><ul><ul><li>Other factors </li></ul></ul><ul><ul><ul><li>Location </li></ul></ul></ul><ul><ul><ul><li>Hazards </li></ul></ul></ul><ul><ul><ul><li>Crowds </li></ul></ul></ul>
  10. 10. Standard of Care <ul><ul><li>“ - - - how a reasonably prudent person with similar training & experience would act under similar circumstances, with similar equipment, and in the same place.” </li></ul></ul>
  11. 11. Standard of Care <ul><li>Law </li></ul><ul><ul><li>Constitutional </li></ul></ul><ul><ul><li>Legislative </li></ul></ul><ul><ul><li>Executive </li></ul></ul><ul><ul><li>Judicial </li></ul></ul>
  12. 12. Standard of Care <ul><li>Professional Standards </li></ul><ul><ul><li>American Heart Association (AHA) </li></ul></ul><ul><ul><li>American Ambulance Association (AAA) </li></ul></ul><ul><ul><li>National Association of Emergency Medical Technicians (NAEMT) </li></ul></ul><ul><ul><li>Texas Department of Health (TDH) </li></ul></ul><ul><ul><li>Department of Transpiration </li></ul></ul>
  13. 13. Standard of Care <ul><li>Institutional Standards </li></ul><ul><ul><li>Service </li></ul></ul><ul><ul><ul><li>Agency Specific Protocol </li></ul></ul></ul><ul><ul><li>Regional Systems </li></ul></ul><ul><ul><ul><li>Regional Trauma Systems / Guidelines </li></ul></ul></ul>
  14. 14. Negligence <ul><li>Simple (Ordinary) Negligence </li></ul><ul><li>Gross Negligence </li></ul><ul><li>Proving Negligence (4 Pillars of Negligence) </li></ul><ul><ul><li>Duty to Act </li></ul></ul><ul><ul><li>Breach of Duty </li></ul></ul><ul><ul><li>Damages </li></ul></ul><ul><ul><li>Causation </li></ul></ul>
  15. 15. Abandonment <ul><li>Failure to Continue Treatment: </li></ul><ul><ul><li>Termination of care without Pt’s consent </li></ul></ul><ul><ul><li>Termination of care without provision for continued care </li></ul></ul><ul><ul><li>Failure to transport </li></ul></ul>
  16. 16. Abandonment <ul><li>Handing Over Care </li></ul><ul><ul><li>EMT > EMT </li></ul></ul><ul><ul><li>EMT > EMT-I </li></ul></ul><ul><ul><li>EMT > EMT-P </li></ul></ul><ul><ul><li>EMT > LVN </li></ul></ul><ul><ul><li>EMT > RN </li></ul></ul><ul><ul><li>EMT > Physician </li></ul></ul>
  17. 17. Adult Consent <ul><li>Adult - Any person over 18 years of age who is not under a court-ordered disability </li></ul><ul><li>Actual Consent (Informed, Expressed) </li></ul><ul><li>Implied Consent </li></ul><ul><ul><li>Pt. is unconscious or unable to communicate and is suffering from what appears to be a life-threatening injury or illness </li></ul></ul>
  18. 18. Adult Consent <ul><li>Involuntary Consent </li></ul><ul><ul><li>An adult may be treated against his will only if: </li></ul></ul><ul><ul><ul><li>Treatment is ordered by a magistrate </li></ul></ul></ul><ul><ul><ul><li>Treatment is ordered by a peace officer or corrections officer who has the patient under arrest or in custody </li></ul></ul></ul>
  19. 19. Adult Consent <ul><li>Consent of the Mentally Incompetent As Deemed by EMS </li></ul><ul><ul><li>Suicidal Ideations or Suicide Attempt </li></ul></ul><ul><ul><ul><li>Encourage patient to transport voluntarily </li></ul></ul></ul><ul><ul><ul><li>Involve Law Enforcement </li></ul></ul></ul><ul><ul><ul><ul><li>Force Transport – have patient placed in custody </li></ul></ul></ul></ul>
  20. 20. Adult Consent <ul><li>Right of Refusal of Treatment/Transport </li></ul><ul><ul><li>Mentally competent adults have the right to refuse care </li></ul></ul><ul><ul><li>the person must be informed of risks, benefits, treatments, & alternatives </li></ul></ul><ul><ul><li>Obtain signature & witness </li></ul></ul>
  21. 21. Minor Consent <ul><li>Minor - any person under 18 years of age who has never been married and who has not had his/her minority status changed by the court </li></ul><ul><ul><li>Pregnant Minor </li></ul></ul><ul><ul><li>Emancipated Minor </li></ul></ul><ul><ul><li>Minor Living Alone and Responsible for 50% of Personal Living Expenses </li></ul></ul>
  22. 22. Minor Consent <ul><li>Actual Consent (Informed, Expressed) </li></ul><ul><ul><li>Parents </li></ul></ul><ul><ul><li>Guardian </li></ul></ul><ul><ul><li>Others Closely Related of Majority Age </li></ul></ul>
  23. 23. Minor Consent <ul><li>Implied Consent </li></ul><ul><ul><li>Life or Limb Threatening </li></ul></ul><ul><ul><li>No Parental Refusal </li></ul></ul>
  24. 24. Minor Consent <ul><li>Right of Refusal of Treatment/Transport </li></ul><ul><ul><li>Mentally competent adults (Parent/Guardian) have the right to refuse care for their children </li></ul></ul><ul><ul><li>the person (Parent/Guardian) must be informed of risks, benefits, treatments, & alternatives </li></ul></ul><ul><ul><li>Obtain signature of Parent/Guardian & witness </li></ul></ul>
  25. 25. Assault & Battery <ul><li>Assault </li></ul><ul><ul><li>Unlawfully placing a person in fear of immediate bodily harm without consent </li></ul></ul><ul><li>Battery </li></ul><ul><ul><li>Unlawfully touching a person </li></ul></ul>
  26. 26. Immunity <ul><li>Governmental (Sovereign) Immunity </li></ul><ul><li>“ Good Samaritan” laws </li></ul><ul><ul><li>Do not prevent lawsuits </li></ul></ul><ul><ul><li>Offer a defense for those who act in “Good Faith” and meet the Standard of Care” </li></ul></ul><ul><ul><li>Do not protect against Gross Negligence </li></ul></ul>
  27. 27. Do Not Resuscitate <ul><li>What Is A OOHDNR? </li></ul><ul><ul><li>O ut O f H ospital D o N ot R esuscitate </li></ul></ul><ul><ul><ul><li>An order that allows patients to direct health care professionals in the out-of-hospital setting to withhold or withdraw specific life-sustaining treatments in the event of respiratory or cardiac arrest. </li></ul></ul></ul>
  28. 28. Do Not Resuscitate <ul><li>“ Living Will”/ “Advance Directives” must be Presented upon Patient Contact </li></ul><ul><li>Determine validity </li></ul><ul><ul><li>May Not be Witnessed by Anyone Who would Benefit from the Death of the Patient </li></ul></ul>
  29. 29. Do Not Resuscitate <ul><li>Texas Law Allows: </li></ul><ul><ul><li>OOHDNR – Original Document </li></ul></ul><ul><ul><li>OOHDNR – Copies of Original Document </li></ul></ul><ul><ul><li>Medallions (DNR Device) </li></ul></ul><ul><ul><ul><li>Medical ID Bracelets / Necklaces </li></ul></ul></ul><ul><ul><ul><li>Laminated Wallet Cards </li></ul></ul></ul>
  30. 30. Do Not Resuscitate <ul><li>Can Include (Any or All) </li></ul><ul><ul><li>Cardiopulmonary resuscitation (CPR) </li></ul></ul><ul><ul><li>Transcutaneous Cardiac </li></ul></ul><ul><ul><li>Defibrillation </li></ul></ul><ul><ul><li>Advanced Airway Management </li></ul></ul><ul><ul><li>Artificial Ventilation </li></ul></ul>
  31. 31. Do Not Resuscitate <ul><li>Determine Specificity as to Levels of Care to Render </li></ul><ul><ul><li>Usually Comfort Measures Only </li></ul></ul><ul><ul><li>Pain Management is SPECIFICALLY Allowed </li></ul></ul><ul><li>If Transporting the Patient </li></ul><ul><ul><li>A copy of the OOHDNR or DNR Device must accompany the patient </li></ul></ul>
  32. 32. Do Not Resuscitate <ul><li>Once Treatment Begins: </li></ul><ul><ul><li>If a Valid OOHDNR is Discovered / Presented </li></ul></ul><ul><ul><ul><li>Cease using CPR, transcutaneous cardiac pacing, defibrillation, advanced airway management and artificial ventilation on the patient </li></ul></ul></ul><ul><ul><ul><li>Provided supportive care as necessary SPECIFICALLY comfort care </li></ul></ul></ul><ul><ul><ul><ul><li>Pain Management </li></ul></ul></ul></ul>
  33. 33. Do Not Resuscitate <ul><li>Conditions To Dishonor a OOHDNR </li></ul><ul><ul><li>The patient is pregnant </li></ul></ul><ul><ul><li>There are unnatural or suspicious circumstances surrounding the death </li></ul></ul><ul><ul><li>The form is not signed twice by all who need to sign it or is filled out incorrectly and no DNR device is present </li></ul></ul><ul><ul><li>An IMMEDIATE family member is protesting the DNR on scene </li></ul></ul>
  34. 34. Do Not Resuscitate <ul><li>A DNR can be revoked at any time by the patient or the person who acted on behalf of the agent. Revocation can be in the form of communication to responding health care professionals, destruction of the form, or removal of devices </li></ul><ul><li>Consider Family Reaction </li></ul>
  35. 35. Do Not Resuscitate <ul><li>IN DOUBT ?? </li></ul><ul><li>TREAT!! </li></ul>
  36. 36. Records & Reports <ul><li>Complete & Accurate </li></ul><ul><li>Legible & Neat </li></ul><ul><ul><li>An untidy or incomplete report is evidence of incomplete or inexpert care. </li></ul></ul><ul><li>Legal Document </li></ul><ul><ul><li>If it wasn’t written down, it didn’t happen! </li></ul></ul>
  37. 37. Patient Confidentiality <ul><li>Patient Confidentiality must be Kept: </li></ul><ul><ul><li>To Ensure the Patient’s Right to Privacy </li></ul></ul><ul><ul><li>To Maintain the EMT’s Reputation of Professionalism </li></ul></ul><ul><ul><li>To Maintain the Service’s Reputation of Professionalism </li></ul></ul><ul><ul><li>It is No One else’s Business! </li></ul></ul>
  38. 38. Patient Confidentiality <ul><li>Patient Information May Only be Released: </li></ul><ul><ul><li>It is necessary to ensure continuity of care </li></ul></ul><ul><ul><li>It is requested by Law Enforcement </li></ul></ul><ul><ul><li>It is required for billing purposes </li></ul></ul><ul><ul><li>It is Subpoenaed </li></ul></ul><ul><ul><li>When the Patient Signs an Information Release Form </li></ul></ul>
  39. 39. Special Reporting Requirements <ul><li>Childbirth </li></ul><ul><li>Child Abuse </li></ul><ul><ul><li>Report to: </li></ul></ul><ul><ul><ul><li>Law Enforcement </li></ul></ul></ul><ul><ul><ul><li>Physician - Emergency Department </li></ul></ul></ul><ul><ul><ul><li>Child Protective Services (CPS) </li></ul></ul></ul><ul><ul><li>Don’t Accuse - Report Observations Only </li></ul></ul><ul><ul><li>Immunity - Good Faith </li></ul></ul>
  40. 40. Special Reporting Requirements <ul><li>Elder Abuse </li></ul><ul><li>Injury During the Commission of a Felony </li></ul><ul><li>Drug Related Injuries </li></ul>
  41. 41. Special Reporting Requirements <ul><li>Crime Scene </li></ul><ul><ul><li>Scene Survey </li></ul></ul><ul><ul><li>Document </li></ul></ul><ul><ul><li>Preserve </li></ul></ul><ul><ul><li>Report to Law Enforcement </li></ul></ul>
  42. 42. Special Reporting Requirements <ul><li>Sexual Assault </li></ul><ul><ul><li>Report to Law Enforcement </li></ul></ul><ul><ul><ul><li>MUST OBTAIN PATIENT’S PERMISSION) </li></ul></ul></ul><ul><ul><li>Retain Evidence </li></ul></ul>
  43. 43. Special Reporting Requirements <ul><li>Dead on Scene </li></ul><ul><ul><li>Document Absence of Vital sign </li></ul></ul><ul><ul><li>Contact Law Enforcement </li></ul></ul><ul><ul><li>Do Not Disturb or Move Body </li></ul></ul><ul><ul><li>Additional Documentation </li></ul></ul><ul><ul><ul><li>All EMS Personnel Present </li></ul></ul></ul><ul><ul><ul><li>Where EMS Stepped </li></ul></ul></ul><ul><ul><ul><li>What EMS Touched </li></ul></ul></ul><ul><ul><ul><li>General Scene Appearance </li></ul></ul></ul>