Legal and Ethical Issues Chapter 4

Topic Overview Standard of care / Scope of practice Consent Informed (Expressed) Implied Children and mentally Incompetent Adults Refusal of Care Advanced Directives Do Not Resuscitate (DNR) orders Living wills.

Objectives Negligence Good Samaritan Laws Confidentiality Duty Legal vs. moral Breach of Duty Abandonment Battery Causation Damages Good Samaritan Laws Confidentiality Crime scene preservation Documentation

Legal and Ethical Considerations Legal Duties All states have established guidelines to allow emergency care to be given without worry of being sued. Laws require a certain “Standard of Care” Standard of Care Care expected based on the provider’s training and experience, taking into account the conditions under which the care is rendered.

Legal and Ethical Considerations Based on laws, administrative orders and guidelines published by the EMS system, organizations and societies. First Responder guidelines established by USDOT State Institutional (PCC and CCE)

Legal and Ethical Considerations Ethical Responsibilities Primary Consideration Make the physical and emotional needs of the patient a priority Additional Responsibilities Maintaining skills and knowledge Includes practicing until you have obtained confidence and mastery of the skills Continuing education and refresher programs Review your performance and assess the techniques you use Evaluate yourself Be honest in reporting care provided

Legal and Ethical Considerations Consent Patient says or acknowledges that you can treat them Expressed Consent Consent given by a rational adult after being informed of the provider’s training and what care procedures are to be done. Risks and options to care.

Legal and Ethical Considerations Implied Consent An unconscious patient is assumed to want help. A legal position that assumes an unconscious or badly injured adult patient would consent to receiving emergency care. May apply to other type of patients as well Mentally ill Children and Mentally Incompetent Adults Parental Consent Serious Injury/Illness in the absence of a parent A form of implied consent

Legal and Ethical Considerations Competence The patient’s ability to understand your questions. The patient’s ability to understand the implications of decisions made. Not competent when: intoxicated drug ingestion serious injury mental incompetence

Legal and Ethical Issues To determine competence Ask Questions PPTE WWWWH Remember answering questions does not always establish competence - Suicidal

Legal and Ethical Considerations Refusal of Care When conscious and competent patients can refuse your care Reasons may be based on religious grounds lack of trust personal reasons You CAN NOT force care on these patients You CAN NOT legally restrain them until EMS arrives

Legal and Ethical Considerations Only Course of Action Try to gain their confidence through conversation When your services are refused: Do Not argue Do Not question their reasons (if based on religious views) Do Not touch Stay Calm and Professional Make sure EMS has been activated Talk to the patient If possible have a neutral witness to your offer to help

Legal and Ethical Considerations If a patient is not competent they cannot refuse medical care or give consent Often times this is where law enforcement becomes involved i.e...mental warrant A parent or guardian can refuse to let you care for a child Follow the previously discussed steps. IF an adult takes a child from the scene before EMS arrives, you must report the incident to EMS or the police Conscious patient refuses care then becomes unconscious, implied consent usually takes over and care begins

Legal and Ethical Considerations Advance Directives DNR (Do Not Resuscitate) Orders Legal document Signed by physician and patient Terminal illness & does not wish to prolong life through resuscitative efforts Texas has a state wide form that must be used The Original DNR form or a copy of the form are to be accepted (NEW) Approved ID bracelet with patient information engraved

Legal and Ethical Considerations Living Wills Document signed by patient regarding use of long-term life support and comfort measures such as respirators, intravenous feedings, pain medications.

Legal and Ethical Considerations Negligence Basis for most lawsuits involving prehospital care is negligence You could be sued IF: You had a Duty to Provide care or you assume the responsibility to provide care Care for the patient was not provided to the “standard of care” Patient was injured in some way as a result of this improper care

Legal and Ethical Considerations Duty to Act While on duty a first responder has a obligation to respond to an emergency and provide care at the scene Your duty to act may involve your office If you volunteer for an organization, you have a duty to act within the respond area of that organization As a Doctor of Chiropractic????? Breach of Duty Substandard care or care given beyond your level of training

Legal and Ethical Considerations Assault / Battery Not a universal definition Unlawful touching of a victim without their consent Providing care when a competent patient refuses care

Legal Considerations In Texas an assault is comparable crime under the Texas Penal Codes. CHAPTER 22. ASSAULTIVE OFFENSES Sec. 22.01. Assault. (a) A person commits an offense if the person: (b) intentionally or knowingly causes physical contact with another when the person knows or should reasonably believe that the other will regard the contact as offensive or provocative. (c) An offense under Subsection (a)(2) or (3) is a Class C misdemeanor, except that an offense under Subsection (a)(3) is a Class A misdemeanor if the offense was committed against an elderly individual or disabled individual, as those terms are defined by Section 22.04.

Legal and Ethical Considerations Cause If duty and breach of duty are established, negligence may be proven if the action or lack of action caused injury (damage) in some form due directly to your actions. Damage Physical damage Moving a patient before a fractured leg is splinted.

Legal and Ethical Considerations Emotional or Psychological Inappropriate care does not always involve a physical skill, it could be you tell someone they don’t need emergency care when they do so EMS is delayed and the delay caused complications Good Samaritan Laws Grant immunity from civil liability if: you acted in good faith you provided care to the best of your ability

Legal and Ethical Considerations Abandonment Once you stop to help you have legally begun care Once you start you have assumed a duty to continue until patient is turned over to more advanced medical personnel (EMS) You have abandoned the patient if: you leave before EMS or a person with higher training arrives and takes over includes the failure to turn over patient information during the transfer to more highly trained personnel

Legal and Ethical Considerations Confidentiality Confidential Information history, gained through interview assessment findings emergency care rendered Releasing Confidential Information Required written release from the patient Not required when EMS personnel need information to continue care Subpoena

Legal and Ethical Considerations Reportable Events Include: exposure to blood and OPIM certain infectious diseases vehicle accidents drug-related injuries crimes resulting in knife or gunshot wounds child and elder abuse domestic violence rape

Legal and Ethical Considerations Special Situations Organ Donors Emergency care must not differ All emergency care measures must be taken including CPR Medical Identification Devices Look for a necklace, bracelet, ankle bracelet, card

Legal and Ethical Considerations Crime Scenes Evidence Preservation Don’t move anything unless care absolutely requires it Note position of the weapon if moved Note the position of the patient Do not cut where the stab or gunshot wound cut the clothing Scene should not be entered until it is secure.

Legal Considerations Documentation If you do not write it down, a court of law would say it did not happen! If paperwork to is sloppy and unreadable, a court of law would say care was also sloppy