Medical/Legal Aspects of Prehospital Care

1. Medical/Legal Aspects of Prehospital Care

2. Topics to Discuss • Legal vs. Ethical vs. Moral Responsibilities • Review of the Legal System • Specific Laws Applicable to EMS • Accountability & Malpractice • Specific Paramedic-Patient Issues • Operational Issues • Documentation

3. Legal vs. Ethical vs. Moral Responsibilities • What are the differences? • Legal Responsibilities • Ethical Standards • Morality

4. The Legal System • Sources of Law • Constitutional • Common • Legislative • Administrative • Legislative and Administrative are often the focus of EMS Providers

5. The Legal System • Federal vs. State Court • Categories of Law • Criminal Law • Civil Law • Tort Law What are examples of how each of these may affect the paramedic?

6. The Legal System • Terminology • Plaintiff • Defendant • Discovery phase • Deposition • Interrogation • Documentation • Appeal

7. Laws Affecting EMS • Scope of Practice • Texas • Medical Direction • Intervener physician • Ability to Practice • Certification or Licensure • Authorization to Practice

8. Laws Affecting EMS • Motor Vehicle Laws • Infectious Disease Exposure • Assault against Public Safety Officer • Obstruction of Duty • Good Samaritan Law • Ryan White CARE Act

9. Laws Affecting EMS • Mandatory Reporting • Domestic violence • Child & Elder abuse • Criminal Acts • GSW, Stabbing & Assault • Animal Bites • Communicable Diseases • Out of hospital deaths • Possession of Controlled Substances

10. Accountability & Malpractice Issues • Standard of Care • Negligence • Civil Litigation Specifics • Borrowed Servant Doctrine • Patient Civil Rights • Liability when off-duty

11. Accountability & Malpractice • Standard of Care • The expected care, skill, & judgment under similar circumstances by a similarly trained, reasonable paramedic • Negligence • Deviation from accepted or expected standards of care expected to protect from unreasonable risk of harm What are the required components for proof of a negligence claim in EMS?

12. Accountability & Malpractice • Civil Cases • Proof of guilt required by a “preponderance of evidence” • “res ipsa loquitur” • Burden of proof shifts to the defendant • Simple vs. Gross Negligence

13. Defenses • Good Samaritan Law • Government Immunity • Statue of Limitations • Contributory Negligence

14. Accountability & Malpractice • How do these affect the Paramedic’s Practice? • Borrowed Servant Doctrine • Patient Civil Rights • Liability when Off-Duty

15. Issues Surrounding Consent Refusals Restraint Abandonment Transfer of Patient Care Advance Directives & End of Life Decisions Out of Hospital Death Confidentiality & Privacy Specific Paramedic-Patient Issues

16. Specific Paramedic-Patient Issues • Issues Surrounding Consent • Patient has legal & mental capacity • Patient understands consequences • Types of Consent • Informed • Expressed • Implied • Involuntary

17. Specific Paramedic-Patient Issues • Issues Surrounding Consent • Specific Consent Issues • Minors • Emancipated Minor • Prisoners

18. Specific Paramedic-Patient Issues • Refusals • Consent for Transport vs. Treatment • Withdrawing Consent • Refusal of Service • Has legal & mental capacity • Is informed of risks & benefits • Offer alternatives • All of the above are well documented & witnessed

19. Specific Paramedic-Patient Issues • Refusals • Incompetent Persons • Unable to understand the nature & consequences of his/her injury/illness • Unable to make rational decisions regarding medical care due to physical or mental conditions • Do not assume incompetence unless obvious

20. Specific Paramedic-Patient Issues • Restraint • Definitions • Assault • Battery • False Imprisonment

21. Specific Paramedic-Patient Issues • Restraint • In Custody of Law Enforcement or Corrections • Patient is not competent to refuse & requires care • Patient is a danger to self or others (involve law enforcement) • Does not provide authorization to harm!

22. Specific Paramedic-Patient Issues • Restraint • Involve Law Enforcement Early • Have a plan of action • Ensure safety of all • Reasonable force • Physical restraints • Chemical restraints • Document well

23. Specific Paramedic-Patient Issues • Patient Abandonment • Unilateral termination of the patient-provider relationship • Still needed and desired • Exceptions • MCI • Risks to well-being • Can a paramedic turn over care of a patient to an EMT?

24. Specific Paramedic-Patient Issues • Transfer of Patient Care • Transfer of Care to other Providers • Transfer of Care at the ED

25. Specific Paramedic-Patient Issues • Advanced Directives & End of Life Decisions • Definitions • Advanced Directive • Out of Hospital DNR • DNR vs. DNAR • Living Will • Durable Power of Attorney for Health Care • Patient Self-Determination Act

26. Specific Paramedic-Patient Issues • Advanced Directives & End of Life Decisions • Living Will • Durable Power of Attorney for Health Care • Texas Out of Hospital DNR • Terminal Condition no longer required • Identification Devices • EMS requirements • Revocation Can a Texas Paramedic honor an Advanced Directive (other than a DNR)?

27. Specific Paramedic-Patient Issues • Advanced Directives & End of Life Decisions • Patient does not surrender rights to receive medical care • Comfort measures appropriate • Provide Family support and guidance • When in doubt, resuscitate & contact medical control • Termination of efforts allowed

28. Specific Paramedic-Patient Issues • Out of Hospital Death • Initiation of care? • Many counties and cities require: • law enforcement response and/or • Justice of the peace pronouncement • Some jurisdictions use a medical examiner or coroner system • Required medical control authorization • Survivors may now be the patients

29. Specific Paramedic-Patient Issues • Patient Confidentiality & Privacy • “Medical information about a patient will not be shared with a third party without consent, statute, or court order” • Not all information is protected • In some states, QA/QI information is not discoverable

30. Specific Paramedic-Patient Issues • Patient Confidentiality & Privacy • Colleague & Station Talk • Must not identify the patient • Maintains confidentiality of specific medical info • Scene or Patient Photographs • EMS Radio Dispatch & Discussions • “Need to Know” Basis

31. Specific Paramedic-Patient Issues • Patient Confidentiality & Privacy • You have treated & transported a 50-year-old local salesman who is originally diagnosed in the ED with PCP. At the station, you discuss this case including the name of the patient’s business. Since PCP is associated with HIV/AIDS, your coworker suspects this man is infected. Your coworker discusses this case with a friend (the patient’s employer) who then discusses this matter with your patient (his employee). (cont’d)

32. Specific Paramedic-Patient Issues Group Discussion: Patient Confidentiality & Privacy 1. What are the possible consequences for you? 2. What if the patient does not have HIV/AIDS?

33. Specific Paramedic-Patient Issues • Patient Confidentiality & Privacy • Defamation • “Communication of false information knowing the information to be false or with reckless disregard of whether it is true or false” • Slander • Libel • Protected Classes/Diseases

34. Equipment failure Interaction with Law Enforcement Crime Scenes Preservation of Evidence Vehicle Operation Medical Control Instructor Liability Hospital Selection Dispatch Interfacility Transfers OSHA Risk Management Operational Issues

35. Operational Issues • Equipment Failure • Product Liability • Design flaw in ventilator • Failure on part of owner/operator • No backup battery for defibrillator

36. Operational Issues • Interaction with Law Enforcement • Crime Scenes • Request law enforcement • Await law enforcement arrival if possible • Minimize areas of travel and contact with scene • Document any alterations to the scene created by EMS personnel • Minimize personnel within scene if possible • Document pertinent observations

37. Operational Issues • Interaction with Law Enforcement • Evidence Preservation • Avoid cutting through penetrations in the clothing • Save everything – clothing of assault victim, items found on person, etc • Prevent sexual assault victim from washing • Follow sound chain of evidence procedures

38. Operational Issues • Vehicle Operation • It is 3:00 am. While responding to a MVC, a driver fails to yield the right of way at an intersection. The driver’s traffic signal is green. You attempt to stop but are unable to do so. Witnesses state your emergency lights were on but do not recall hearing your siren. The driver is injured.(cont’d)

39. Operational Issues • Vehicle Operation • What issues might the driver’s attorney consider? • Were all of your emergency lights really operational? Are daily inspections performed? • Why was the siren not working? • Were poorly maintained brakes responsible for your inability to stop? What type of PM is performed on your ambulance? • Did you exercise due regard for the safety of others?

40. Operational Issues • Medical Control Issues • Failure to follow med contr direction • Following obviously harmful direction • Implementing therapies without prior authorization • Following direction of an unauthorized person • Med Contr directs EMS to an inappropriate hospital • The paramedic exceeds the scope of his training or medical authorization

41. Operational Issues • Instructor Liability • Student discrimination • Sexual harassment • Student injury during laboratory • Patient claim re. Failure to properly train graduate or supervise student • Instructors – Follow curriculum, document student attendance & competency

42. Operational Issues • Hospital Selection • Paramedic & Medical Control decision • Closest & Appropriate Facility • Written policies or guidelines What is the closest & most appropriate facility? What does this mean?

43. Operational Issues • Dispatch Issues • Untimely dispatch • Failure to provide responding units with adequate directions (incorrect address) • Dispatch of inadequate level of care • Failure to provide pre-arrival instructions • Inadequate recordkeeping

44. Operational Issues • Interfacility Transfer Issues • Do you have the necessary equipment & training? • Should any specialized providers accompany you? • Do you have a patient report including history? • Is the patient “stable”? What are the potential complications? • Are there any specific physician orders? • Does the patient have a DNR order? • Has the patient been accepted (MOT)? Who are the transferring & accepting physicians?

45. Operational Issues • OSHA & Risk Management • OSHA generally not applicable to government employees • New Texas Sharp Injury Prevention Rules • In many States, State OSHA Rules are applicable to nearly all • “Each employee shall comply with occupational safety and health standards and all rules, regulations, and orders issued persuant to this Act which are applicable to his own actions and conduct”

46. Documentation • Patient Confidentiality • Securing/Sharing/Requests for Information • Protected Classes • Quality & Effectiveness

47. Documentation • Patient Confidentiality • Written report only intended for those with a need to know • Personal identifiers may be removed for QA/QI uses • Patient radio reports should not contain personal identifiers

48. Documentation • Securing/Sharing/Requests for Information • Where are completed patient reports stored? • Who received the report at the ED? • Requests for copies should be routed through an accepted policy or an attorney • Does the requestor have a need to know?

49. Documentation • Protected Classes • In some states, patient information related to sexually transmitted diseases or other specific diseases has become protected as confidential • Washington state • Can not refer to HIV/AIDS or STD status in report without consent • Then, only with a clear need to know

50. Documentation • Quality & Effectiveness • Complete soon after the patient contact • Be thorough and accurate • Be honest, objective and factual • Caution with abbreviations • Maintain confidentiality • Do not alter