LEGAL AND ETHICAL ISSUES

1. LESSON 3 LEGAL AND ETHICAL ISSUES

2. Introduction • Lawsuits against EMRsare rare • Adhere to basic legal principles regarding emergency care • State laws vary

3. Regulations • Federal, state and local laws and regulations govern practice of emergency medicine • Requirements vary for registering or becoming certified EMR • Laws state what EMRcan and can’t do

4. Scope of Practice • Level of care health care professional provides with specified level of training • Defined by United States DOT National Emergency Medical Services Education Standards (NHTSA) • State laws may modify scope of practice • Further defined through medical oversight, including protocols, standing orders, direct oversight

5. Standard of Care • Howyou provide care and whatspecific care you give • Same care as EMR with similar training would give patient in similar circumstances • National standard of care based on DOT National Emergency Medical Services Education Standards • What you are taught in EMR training = standard of care • Give care as you have been taught, and you cannot be held legally liable for a negative patient outcome • Neglecting to follow standard of care may make you liable for negligence

6. Primary Ethical Principles in Health Care • Do no harm • Act in good faith • Act in the patient’s best interest

7. Ethical Responsibilities • To provide the best patient care possible • Make patient’s physical and emotional needs your highest priority • Practice care giving skills until mastered • Regularly attend continuing education and refresher programs • Review your performances after each patient care episode • Be honest in reporting and documentation

8. Consent • Patients have right to decide emergency care they will accept • Obtain person’s consent before providing care • Consent based on information you provide • A competent adult has right to refuse care

9. Competence • Determine if adult patient is competent to consent • Competent person can understand what is happening and implications of receiving/refusing care • Patient may not be competent because of intoxication, drug use or altered mental status caused by severe injury • Parent or legal guardian gives consent for children or mentally incompetent adults • If parent or guardian cannot be reached, consent is implied

10. ExpressedConsent • Patient explicitly grants permission for care • Usually a verbal agreement or a nod • Must be obtained from every responsive, competent adult before giving care • Patient must be informed

11. To Obtain Expressed Consent • Identify yourself to patient • State your level of training • Explain what you think may be wrong • Describe care you will give and its benefits • Explain any risks related to care

12. Implied Consent • Unresponsive patient assumed to give consent • Consent assumed for child needing emergency care if parent or guardian is not present

13. Refusal of Consent • Competent adult patients have right to refuse medical care • You must honor their wishes • May be verbal or indicated by shaking head or pulling away • Person should fully understand all risks and consequences of refusing care • After treatment begins, patient still has right to withdraw

14. When a Patient Refuses Consent • When in doubt, err in favor of providing care • Do not argue with patient or question patient’s personal beliefs • Follow local protocol • Notify responding EMS units to evaluate situation • Have patient sign refusal form or have witness hear patient’s refusal

15. While Awaiting Additional EMS Resources(If Consent is Refused) • Try again to persuade patient to accept care • Determine whether patient is competent • Inform patient again why care is needed and what may happen if care is refused • Consult medical oversight as directed by local protocol • Consider calling for assistance from law enforcement • Report assessment findings and emergency medical care you have provided

16. Types of Law • Criminal Law • Regulatory Law • State Medical Practice Acts (Statutory Law) • Civil Law (Tort Law)

17. Assault and Battery • Assault: crime of verbally or physically threatening to touch another person without consent • Battery: crime of touching another person without consent • Caring for a competent patient who refuses care may make you guilty of assault or battery • Patient may file lawsuit against you

18. Advance Directives • Legal document • Identifies care person will or will not accept • Signed while the person is competent • Durable power of attorney for health care • Do Not Resuscitate (DNR) order • Generally must be signed and witnessed, and may require a physician’s signature

19. If You Encounter an Advance Directive • Follow local protocol • DNR refers only to resuscitative care for patient whose heart has stopped  not other treatment • If any doubt, or if written directive is not present, give care as usual • Other adults and family members cannot refuse care for patient without formal advance directive • If family members ask you to provide care, even when DNR order is present, give care until responding EMS professionals arrive

20. Abandonment • Once you have begun emergency care, you have a legal obligation to continue • Obligation to render care ends when someone with equal or higher training takes over • Failing to continue care before another EMR or EMT takes over makes you guilty of abandonment, a form of negligence • Assessing also is considered care: • If you assess and release patient and patient later dies or suffers, you are guilty of abandonment • Leaving a patient who refuses care, without waiting for EMTs to arrive and assess patient, may also be abandonment

21. Abandonment: Failure to Attempt Resuscitation • If you believe person is dead and do not attempt resuscitation, you may be guilty of abandonment • Conditions in which death can be assumed include decapitation, rigor mortis, tissue decomposition • If unsure what to do in any situation, call medical control for advice

22. Negligence • Failing to give care following the accepted standard of care • Includes not giving care and giving improper or poor-quality care • If the patient suffers further injury or disability, you may be sued for negligence

23. Conditions forNegligence May be negligent if: • You have a duty to act • You breach that duty • The patient suffers injury or damage (including pain and suffering) • Your actions (or inactions) caused the injury or damage

24. Good Samaritan Laws Protect you: • When acting in an emergency, voluntarily and without compensation • When acting as a reasonable, prudent person with the same training would act • When performing emergency care as trained

25. Confidentiality • When gathering patient’s history, you may learn private information • Assessment findings and emergency care provided are confidential • You have ethical responsibility to respect patient’s right to privacy • Never share patient information with others, including family members and coworkers • Do share information with EMS or health care personnel, and with mandatory reporting

26. Health Insurance Portability and Accountability Act • Health Insurance Portability and Accountability Act (HIPAA) ensures confidentiality of all patient information legally protected • You must not disclose any patient information except to others providing treatment, law enforcement personnel or when subpoenaed by a court • Violations may lead to civil or criminal penalties • Follow the policies of your EMS system • When in doubt, consider everything you know about a patient to be confidential • A written release form signed by patient is required to share information

27. Special Situations Legal considerations are involved in other situations such as: • Medical identifications • Crime scenes • Reportable events • Documentation

28. Medical Identification Insignia • Include necklaces, bracelets, cards worn or carried • Used by patients with certain medical conditions such as allergies, diabetes, epilepsy and heart conditions • Not looking for such insignia during patient assessment may be negligence

29. Crime Scenes • Care of the patient remains the top priority • At potential crime scene, take precautions to preserve evidence • Make sure scene is safe before entering • Ensure law enforcement personnel are responding • Do not disturb any item at scene unless emergency care requires it

30. Crime Scenes (continued) • Observe and document anything unusual at scene • When removing clothing to expose injury, do not cut through holes from gunshot or stabbing wounds • Follow directions of law enforcement personnel, and explain what is necessary to provide essential patient care

31. Reportable Events • EMRsare obligated to report: • Child, elder, and spouse abuse or domestic violence • Crimes, such as gunshot and knife wounds, suspicious burns, rape and sexual assault • Vehicle crashes • Certain infectious diseases • Exposure to a patient’s body fluids • Always fully document your objective findings

32. Documentation • Documenting patient assessment and care is very important • Helps other EMS professionals assess and treat patient. • Because patient’s condition often changes, report of early assessments provides key information • Your record is a legal document that helps support what you saw, heard, and did at scene • Complete the record as soon as possible after the emergency • State and local EMS requirements for documentation vary • Many EMS systems have printed forms used by EMR