Limmer et al., Emergency Care, 11th Edition © 2009 by Pearson Education, Inc., Upper Saddle River, NJ DOT Directory Chapter 3 Medical/Legal and Ethical Issues

Limmer et al., Emergency Care, 11th Edition © 2009 by Pearson Education, Inc., Upper Saddle River, NJ DOT Directory U.S. DOT Objectives Directory U.S. DOT Objectives are covered and/or supported by the PowerPoint™ Slide Program and Notes for Emergency Care, 11th Ed. Please see the Chapter 3 correlation below. *KNOWLEDGE AND ATTITUDE Define the EMT scope of practice. Slides Discuss the importance of do not resuscitate (DNR) orders (advance directives) and local or state provisions regarding EMS application. Slides Define consent and discuss the methods of obtaining consent. Slides 7-8, Differentiate between expressed and implied consent. Slides Explain the role of consent of minors in providing care. Slides 9, Discuss the implications for the EMT in patient refusal of transport. Slides 12, 14-18, Discuss the issues of abandonment, negligence, and battery and their implications to the EMT. Slides 19, State the conditions necessary for the EMT to have a duty to act. Slides (cont.)

Limmer et al., Emergency Care, 11th Edition © 2009 by Pearson Education, Inc., Upper Saddle River, NJ DOT Directory U.S. DOT Objectives Directory *KNOWLEDGE AND ATTITUDE Explain the importance, necessity, and legality of patient confidentiality. Slides Discuss the considerations of the EMT in issues of organ retrieval. Slides Differentiate the actions that an EMT should take to assist in the preservation of a crime scene. Slides State the conditions that require an EMT to notify local law enforcement officials. Slides Explain the role of EMS and the EMT regarding patients with DNR orders. Slides Explain the rationale for the needs, benefits, and usage of advance directives. Slides Explain the rationale for the concept of varying degrees of DNR. Slides

Limmer et al., Emergency Care, 11th Edition © 2009 by Pearson Education, Inc., Upper Saddle River, NJ DOT Directory Scope of Practice

Limmer et al., Emergency Care, 11th Edition © 2009 by Pearson Education, Inc., Upper Saddle River, NJ DOT Directory A collective set of regulations, duties, and ethical considerations that define your role as an EMT Scope of Practice of an EMT

Limmer et al., Emergency Care, 11th Edition © 2009 by Pearson Education, Inc., Upper Saddle River, NJ DOT Directory Patient Medical direction State legislation Who is the EMT accountable to?

Limmer et al., Emergency Care, 11th Edition © 2009 by Pearson Education, Inc., Upper Saddle River, NJ DOT Directory Patient Consent and Refusal

Limmer et al., Emergency Care, 11th Edition © 2009 by Pearson Education, Inc., Upper Saddle River, NJ DOT Directory Receiving permission from the patient prior to treatment or action by the EMT Definition of Consent

Limmer et al., Emergency Care, 11th Edition © 2009 by Pearson Education, Inc., Upper Saddle River, NJ DOT Directory Expressed/Informed/Actual Implied Consent to treat minors or mentally incompetent patients Three Types of Consent

Limmer et al., Emergency Care, 11th Edition © 2009 by Pearson Education, Inc., Upper Saddle River, NJ DOT Directory The consent given by adults who are of legal age and who are mentally competent to make a rational decision in regard to their medical well-being Expressed/Informed/Actual

Limmer et al., Emergency Care, 11th Edition © 2009 by Pearson Education, Inc., Upper Saddle River, NJ DOT Directory In the case of an unconscious patient, consent may be assumed. The law states that rational patients would consent to treatment if they were conscious. Implied Consent

Limmer et al., Emergency Care, 11th Edition © 2009 by Pearson Education, Inc., Upper Saddle River, NJ DOT Directory Children and mentally incompetent adults are not legally allowed to provide consent or refuse medical care and transportation. Children and Mentally Incompetent Adults

Limmer et al., Emergency Care, 11th Edition © 2009 by Pearson Education, Inc., Upper Saddle River, NJ DOT Directory Emancipated minors may give informed consent. Emancipated Minor Person younger than age 18 who is: –Married –Pregnant –A parent –A member of the armed forced –Financially independent and living away from home

Limmer et al., Emergency Care, 11th Edition © 2009 by Pearson Education, Inc., Upper Saddle River, NJ DOT Directory You will find that some patients who require treatment and transportation to the hospital will refuse care. Patient Refusal (cont.)

Limmer et al., Emergency Care, 11th Edition © 2009 by Pearson Education, Inc., Upper Saddle River, NJ DOT Directory In order for a patient to refuse care or transport, several conditions must be fulfilled: – Patient must be legally able to consent. – Patient must be a mentally competent adult. – Patient must be fully informed. – Patient must sign a “release” form. Patient Refusal (cont.)

Limmer et al., Emergency Care, 11th Edition © 2009 by Pearson Education, Inc., Upper Saddle River, NJ DOT Directory When in doubt, err in favor of providing care! Patient Refusal

Limmer et al., Emergency Care, 11th Edition © 2009 by Pearson Education, Inc., Upper Saddle River, NJ DOT Directory Options for Patient Refusal Utilize others to help: –Family members may help convince the patient. –Medical direction may assist. –Law enforcement may have legal options.

Limmer et al., Emergency Care, 11th Edition © 2009 by Pearson Education, Inc., Upper Saddle River, NJ DOT Directory Documenting Patient Refusal Documentation is key to protection* –Note all physical findings. –Attempt to persuade patient to accept care. –Outline risks and consequences as explained. *Poor documentation on patient refusals is the leading cause of lawsuits.

Limmer et al., Emergency Care, 11th Edition © 2009 by Pearson Education, Inc., Upper Saddle River, NJ DOT Directory Unlawfully touching a patient without consent can be considered battery. Providing care without consent Assault/Battery

Limmer et al., Emergency Care, 11th Edition © 2009 by Pearson Education, Inc., Upper Saddle River, NJ DOT Directory Patient Refusal Checklist

Limmer et al., Emergency Care, 11th Edition © 2009 by Pearson Education, Inc., Upper Saddle River, NJ DOT Directory Advance Directives

Limmer et al., Emergency Care, 11th Edition © 2009 by Pearson Education, Inc., Upper Saddle River, NJ DOT Directory Do Not Resuscitate order (DNR) Living wills Healthcare proxies Three Types of Advance Directives

Limmer et al., Emergency Care, 11th Edition © 2009 by Pearson Education, Inc., Upper Saddle River, NJ DOT Directory This is a legal document. Signed by the patient and his physician Patient has a terminal illness and does not wish to prolong life through resuscitative efforts. Do Not Resuscitate Order (DNR) (cont.)

Limmer et al., Emergency Care, 11th Edition © 2009 by Pearson Education, Inc., Upper Saddle River, NJ DOT Directory Become familiar with protocols prior to need. When in doubt, resuscitate. Do Not Resuscitate Order (DNR)

Limmer et al., Emergency Care, 11th Edition © 2009 by Pearson Education, Inc., Upper Saddle River, NJ DOT Directory Do Not Resuscitate (DNR) Order

Limmer et al., Emergency Care, 11th Edition © 2009 by Pearson Education, Inc., Upper Saddle River, NJ DOT Directory Ethical, Medical, and Legal Issues

Limmer et al., Emergency Care, 11th Edition © 2009 by Pearson Education, Inc., Upper Saddle River, NJ DOT Directory Make patient’s needs a priority. Maintain skills and knowledge. Critically review performance (Quality Improvement). Prepare honest reports. Ethical Responsibilities

Limmer et al., Emergency Care, 11th Edition © 2009 by Pearson Education, Inc., Upper Saddle River, NJ DOT Directory Deviation from accepted standards of care recognized by law for the protection of others against the unreasonable risk of harm “Something that should have been done but was not, or was done incorrectly” Negligence

Limmer et al., Emergency Care, 11th Edition © 2009 by Pearson Education, Inc., Upper Saddle River, NJ DOT Directory Duty to act Breach of that duty Actual damages Proximate cause Elements of Proving Negligence

Limmer et al., Emergency Care, 11th Edition © 2009 by Pearson Education, Inc., Upper Saddle River, NJ DOT Directory An obligation to provide emergency care Formal duty: Contractual obligation between agency and municipality Implied duty: Call to 911; beginning care for patient Duty to Act

Limmer et al., Emergency Care, 11th Edition © 2009 by Pearson Education, Inc., Upper Saddle River, NJ DOT Directory Off duty Out of your EMS system but in an ambulance Off duty but in uniform Duty to Act: Ethical/Moral

Limmer et al., Emergency Care, 11th Edition © 2009 by Pearson Education, Inc., Upper Saddle River, NJ DOT Directory An action or inaction that violates the standard of care expected from an EMT Breach of Duty (cont.)

Limmer et al., Emergency Care, 11th Edition © 2009 by Pearson Education, Inc., Upper Saddle River, NJ DOT Directory Breach of Duty Malfeasance –Performance of a wrongful or unlawful act by an EMT Misfeasance –Performance of a legal act in a harmful or injurious manner Nonfeasance –Failure to perform a required act or duty

Limmer et al., Emergency Care, 11th Edition © 2009 by Pearson Education, Inc., Upper Saddle River, NJ DOT Directory Refers to compensable physical, psychological, or financial harm Actual Damages

Limmer et al., Emergency Care, 11th Edition © 2009 by Pearson Education, Inc., Upper Saddle River, NJ DOT Directory An action or inaction that immediately caused or worsened the damage Proximate Cause

Limmer et al., Emergency Care, 11th Edition © 2009 by Pearson Education, Inc., Upper Saddle River, NJ DOT Directory Termination of care of a patient without assuring continuation of care at the same level or higher Abandonment

Limmer et al., Emergency Care, 11th Edition © 2009 by Pearson Education, Inc., Upper Saddle River, NJ DOT Directory Provides immunity to individuals trying to help people in emergencies Most state laws will grant immunity from liability if the rescuer acts in good faith to provide care to the level of his training and to the best of his ability. Good Samaritan Law

Limmer et al., Emergency Care, 11th Edition © 2009 by Pearson Education, Inc., Upper Saddle River, NJ DOT Directory Any information you obtain about a patient’s history, condition, or treatment is considered confidential and must not be shared with anyone else. Confidential Information (cont.)

Limmer et al., Emergency Care, 11th Edition © 2009 by Pearson Education, Inc., Upper Saddle River, NJ DOT Directory Confidential Information Exception to written release: –Subpoena –Other healthcare personnel treating patient –Mandatory reporting (rape, abuse) –Insurance

Limmer et al., Emergency Care, 11th Edition © 2009 by Pearson Education, Inc., Upper Saddle River, NJ DOT Directory HIPAA The Health Insurance Portability and Accountability Act mandates increased privacy of patient-specific medical information and its: –Record keeping –Storage –Access –Discussion

Limmer et al., Emergency Care, 11th Edition © 2009 by Pearson Education, Inc., Upper Saddle River, NJ DOT Directory Medical Identification Devices Alert EMT to patient’s medical condition, such as: –Heart condition –Diabetes –Allergies –Epilepsy –Other information

Limmer et al., Emergency Care, 11th Edition © 2009 by Pearson Education, Inc., Upper Saddle River, NJ DOT Directory Medical Identifications Devices (Front)

Limmer et al., Emergency Care, 11th Edition © 2009 by Pearson Education, Inc., Upper Saddle River, NJ DOT Directory Medical Identification Devices (Back)

Limmer et al., Emergency Care, 11th Edition © 2009 by Pearson Education, Inc., Upper Saddle River, NJ DOT Directory An organ donor is a patient who has completed a legal document that allows for donation of organs in the event of his death. A patient’s driver’s license may also indicate that the patient wishes to donate organs upon his death. Organ Donation

Limmer et al., Emergency Care, 11th Edition © 2009 by Pearson Education, Inc., Upper Saddle River, NJ DOT Directory Organ donor patients are treated the same as other patients. Identify potential donors. Notify medical direction. Provide care to maintain vital organs. EMT Role in Organ Donation

Limmer et al., Emergency Care, 11th Edition © 2009 by Pearson Education, Inc., Upper Saddle River, NJ DOT Directory Organ Donor Form

Limmer et al., Emergency Care, 11th Edition © 2009 by Pearson Education, Inc., Upper Saddle River, NJ DOT Directory Defined as the location where a crime has been committed or any place that evidence relating to a crime may be found. Crime Scenes (cont.) © Craig Jackson/In the Dark Photography

Limmer et al., Emergency Care, 11th Edition © 2009 by Pearson Education, Inc., Upper Saddle River, NJ DOT Directory Do not enter the crime scene until it is safe. Patient care is the priority. Remain alert for evidence and try not to disturb it. Crime Scenes (cont.)

Limmer et al., Emergency Care, 11th Edition © 2009 by Pearson Education, Inc., Upper Saddle River, NJ DOT Directory Be observant. Minimize your impact on the scene. Remember what you touch. Plan and communicate with the police. Crime Scenes

Limmer et al., Emergency Care, 11th Edition © 2009 by Pearson Education, Inc., Upper Saddle River, NJ DOT Directory Abuse (child, spouse, elderly) Sexual assault Gunshot wound Infectious disease exposure Special Crimes and Reporting

Limmer et al., Emergency Care, 11th Edition © 2009 by Pearson Education, Inc., Upper Saddle River, NJ DOT Directory Restraint MCI Other unusual situations Mandatory reporting laws vary from state to state. Special Reporting Situations

Limmer et al., Emergency Care, 11th Edition © 2009 by Pearson Education, Inc., Upper Saddle River, NJ DOT Directory 1. Define scope of practice, negligence, duty to act, abandonment, and confidentiality. 2. List several steps that must be taken when a patient refuses care or transportation. 3. List several types of evidence and ways you may act to preserve it at a crime scene. Review Questions

Limmer et al., Emergency Care, 11th Edition © 2009 by Pearson Education, Inc., Upper Saddle River, NJ DOT Directory Was it appropriate not to include the information that the patient has AIDS during the radio report to the hospital? What is the obligation of these EMTs concerning the confidentiality of patient information? Street Scenes (cont.)

Limmer et al., Emergency Care, 11th Edition © 2009 by Pearson Education, Inc., Upper Saddle River, NJ DOT Directory Would you have handled the transfer of information differently? Would it be appropriate to tell all the hospital staff so they would know to take infection precautions? Street Scenes (cont.)

Limmer et al., Emergency Care, 11th Edition © 2009 by Pearson Education, Inc., Upper Saddle River, NJ DOT Directory Should the information that this patient has AIDS be shared with other EMS providers in case they get a call for this patient? Street Scenes (cont.)

Limmer et al., Emergency Care, 11th Edition © 2009 by Pearson Education, Inc., Upper Saddle River, NJ DOT Directory What are the principles for confidentiality that EMTs should always maintain? Street Scenes