Medical/Legal and Ethical Issues CHAPTER 3 Medical/Legal and Ethical Issues

Scope of Practice A collective set of rules and duties that define your role as an EMT–B

Legal Duties of the EMT-B Providing patient care within the scope of practice State Legislation – further defined by medical direction through the use of protocols and standing orders Medical Direction – scope of practice may be contingent upon telephone/radio communications and approved standing orders/protocols

Ethical Responsibilities Make patient's needs a priority (physical/emotional). Maintain skills and knowledge to the point of mastery. Critically review performance, seeking ways to improve response time, patient outcome, communication. (Quality Improvement) Prepare honest reports. Maintain confidentiality

Advance Directives

Advance Directives: DNR Orders Patient has the right to refuse resuscitative efforts. Usually requires written physician order on a NYS DOH form – you need to make sure you see this, and it is only valid for six months

Advance Directives: DNR Orders Become familiar with protocols related to DNR orders and advance directives Prehospital DNRs honored Health Care Proxy not honored in the prehospital setting (only in the hospital setting) When in doubt, resuscitate.

Do Not Resuscitate (DNR) Order

Types of Consent

Consent: Expressed/Informed Patient of legal age and able to make a rational decision Must be informed of the steps of the procedures and all related risks Must be obtained from conscious, mentally competent adults before treatment

Consent: Implied Consent implied for unconscious patient requiring emergency intervention Based on the assumption the unconscious patient would consent if conscious

Consent: Children and Incompetent Adults Consent required from parent/guardian Emancipation Issues (those who are married or of a certain age) State regulations regarding age of minors Consent implied in life-threatening emergency

Patient Refusal Patients have the right to refuse treatment if they: are legally able to refuse are mentally competent following the rules of informed consent are fully informed of risks sign a “release of liability” form if an unconscious patient regains consciousness, and refuses transport

Patient Refusal When in doubt, err in favor of providing care!

Documenting Patient Refusal Leading cause of lawsuits Documentation is key to protection. Note all assessment findings and emergency medical care given. Attempt to persuade patient to accept care. Ensure the patient is able to make a rational, informed decision Outline risks & consequences as explained.

Options for Patient Refusal Utilize others to help: Family members may help convince patient. Medical control may assist. Law enforcement may have legal options. THE EMT-BASIC SHOULD NEVER MAKE AN INDEPENDENT DECISION NOT TO TRANSPORT

Patient Refusal Checklist

Assault/Battery Unlawfully touching patient without consent can be considered battery. Providing care when the patient does not consent to the treatment

Ethical, Medical, Legal Issues

Key Term Abandonment Termination of care of a patient without assuring continuation of care at the same level or higher (we must hand over care to an EMT-I or Paramedic/at the hospital)

Key Term Negligence Deviation from accepted standard of care, resulting in further injury to a patient “Something that should have been done but was not, or was done incorrectly”

Negligence: Components Duty to act Breach of that duty (may include failure to act/did not provide standard of care) Injury or damages inflicted (physical or psychological) The actions of the EMT-B caused the injury/damage

Duty to Act An obligation to provide emergency care to a patient Formal Duty: Contractual obligation between agency and municipality (specific clauses within the contract should indicate when service can be refused to a patient) Implied Duty: Patient call to 9-1-1 and dispatcher confirms that an ambulance will be sent Treatment is begun on patient

Duty to Act: Ethical/ Moral There are no NYS laws regarding duty to act: Off duty Out of your EMS system, but in an ambulance Good Samaritan laws

Confidential Information Patient history gained through interview Assessment findings Treatment rendered Written release required to release information signed by the patient. Do not release on request, written or verbal, unless legal guardianship has been established

Confidential Information Exceptions to written release: Legal Subpoena Other health care personnel treating patient need to know information to continue care Mandatory reporting (rape, abuse) Insurance – 3rd party payment billing forms Statewide data collection system (PCRs)

HIPAA Health Insurance Portability and Accountability Act mandates increased privacy of patient-specific medical information and their: Record keeping Storage Access Discussion – when medically necessary

Organ Donation Requires a separate signed donor form. Driver's license shows intent to be a donor on reverse side.

Organ Donor Form

EMT–B Role in Organ Donation Organ donor patients are treated the same as other patients. Identify potential donors. Notify medical direction. Provide care to maintain vital organs.

Medical Identification Devices Alert EMT–B to patient’s medical condition Heart conditions Diabetes Allergies (bees, medicines, foods, etc…) Epilepsy Other information

Medical Identification Device (front)

Medical Identification Device (back)

Crime Scenes Do not enter the crime scene until it is safe – scene is “RED” until secured by police. Patient care is the priority. If possible, do not cut through holes in clothing from gunshot wounds or stabbing wounds Remain alert for evidence and try not to disturb it unless you need to, to provide emergency care. Evidence deals with condition of the scene, the patient, fingerprints/footprints, and microscopic evidence

Crime Scenes Be observant and document anything unusual at the scene. Minimize your impact on the scene. Remember what you touch and report it to police. Plan and communicate with the police.

Special Reporting Situations Abuse (child, spouse, elderly) (physical, sexual, emotional) Sexual assault/Rape Gunshot wound Infectious disease exposure

Special Reporting Situations Restraint MCI Other unusual situations Mandatory reporting laws vary from state to state.