3: Medical, Legal, and Ethical Issues

Define the EMT-B’s scope of practice Discuss the importance of DNR orders (advance directives) and local and state provisions regarding EMS application Define consent and discuss the methods of obtaining consent Differentiate between expressed and implied consent. Cognitive Objectives (1 of 3)

Explain the role of consent of minors in providing care Discuss the implications for the EMT-B in patient refusal of transport Discuss the issues of abandonment, negligence, and battery and their implications for the EMT-B State conditions necessary for the EMT-B to have a duty to act. Cognitive Objectives (2 of 3)

Explain the importance, necessity, and legality of patient confidentiality Discuss the considerations of the EMT-B in issues of organ retrieval Differentiate the actions that an EMT-B should take in the preservation of a crime scene State the conditions that require an EMT-B to notify law enforcement officials. Cognitive Objectives (3 of 3)

5 Affective Objectives Explain the role of EMS and the EMT-B regarding patients with DNR orders Explain the rationale for the needs, benefits, and usage of advance directives Explain the rationale for the concept of varying degrees of DNR. There are no psychomotor objectives for this chapter.

6 Medical, Legal, and Ethical Issues Scope of practice –Defined by state law –Outlines care you can provide –Further defined in protocols and standing orders –Authorized through online and off-line medical direction

7 Standard of Care (1 of 2) Standard imposed by local custom –Often based on locally accepted protocols Standard imposed by the law –May be imposed by statutes, ordinances, administrative guidelines, or case law

8 Standard of Care (2 of 2) Professional or institutional standards –Recommendations published by organizations and societies –Specific rules and procedures of your service or organization

9 Standards Imposed by States Medical Practices Act –Exempts EMT-Bs from licensure requirements Certification –Process of evaluating and recognizing that EMT-B has met certain predetermined standards

10 Duty to Act Individual’s responsibility to provide patient care. Responsibility to provide care comes from either statute or function. Legal duty to act begins once an ambulance responds to a call or treatment is initiated. No legal duty to act when off duty

11 Negligence Failure to provide the same care that a person with similar training would provide

12 Negligence Determination (1 of 2) Duty –Responsibility to act reasonably based on standard of care Breech of duty –Failure to act within expected and reasonable standard of care

13 Negligence Determination (2 of 2) Damages –Physical or psychological harm created in a noticeable way Cause –Existence of reasonable cause and effect. All four must exist for negligence to apply.

14 Abandonment Termination of care without patient’s consent Termination of care without provisions for continued care Care cannot stop unless someone of equal or higher training takes over

15 Consent Expressed consent Implied consent Minors Mentally incompetent adults Forcible restraints

16 Assault and Battery Assault –Unlawfully placing a person in fear of immediate bodily harm without consent Battery –Unlawfully touching a person Some states have grades of assault, no battery

17 Refusal of Treatment Mentally competent adults have the right to refuse care. Patients must be informed of risks, benefits, treatments, and alternatives. EMT-B should obtain a signature and have a witness present, if possible.

18 Good Samaritan Laws and Immunity Good Samaritan –Based on the principle that you should not be liable when assisting another in good faith Immunity –Usually reserved for governments

19 Advance Directives Specifies medical treatments desired if patient is unable to make decisions Do not resuscitate (DNR) orders –Patients have the right to refuse resuscitative efforts. –Require a written order from one or more physicians –When in doubt, begin resuscitation.

20 Ethical Responsibilities Make the physical/emotional needs of the patient a priority. Practice/maintain skills to the point of mastery. Critically review performances. Attend continuing education/refresher programs. Be honest in reporting.

21 Confidentiality Information received from or about a patient is considered confidential. Disclosing information without permission is considered a breach of confidentiality. Generally, information can only be disclosed if the patient signs a written release.

22 HIPAA Safeguards patient confidentiality. Limits EMS providers from obtaining follow-up information. Releases health information only with patient’s permission.

23 Records and Reports Complete documentation is a safeguard against legal complications. If an action or procedure is not recorded, courts assume it was not performed. An incomplete or untidy report is considered evidence of incomplete or inexpert care.

24 Special Reporting Requirements (1 of 2) Abuse of children, elderly, and spouse Injury during the commission of a felony Drug-related injury Childbirth

25 Special Reporting Requirements (2 of 2) Infectious disease exposure Crime scene Deceased

26 Physical Signs of Death Death is the absence of circulatory and respiratory function. If the body is still warm, initiate care. If hypothermia is present, initiate care.

27 Presumptive Signs of Death Unresponsive to painful stimuli Lack of pulse or heartbeat Absence of breath sounds No deep tendon or corneal reflexes Absence of eye movement No systolic blood pressure Profound cyanosis Decreased body temperature

28 Definitive Signs of Death Obvious mortal injury Dependent lividity Rigor mortis Putrefaction (decomposition of body)

29 Medical Examiner Cases DOA Unknown cause of death Suicide Violent death Poisoning Accidents Suspicion of criminal action

30 Special Situations Organ donors Medical identification insignia

31 Review 1.You arrive at the scene of an elderly lady complaining of chest pain. In assessing her, she holds her arm out for you to take her blood pressure. This is an example of: A. implied consent. B. informed consent. C. expressed consent. D. emergency consent.

32 Review Answer: C Rationale: Expressed consent (also called actual consent) is when the patient authorizes you to provide treatment and transport, either verbally or nonverbally. For example, a patient who holds out his or her arm to allow you take a blood pressure is nonverbally giving you expressed consent.

33 Review 1.You arrive at the scene of an elderly lady complaining of chest pain. In assessing her, she holds her arm out for you to take her blood pressure. This is an example of: A.implied consent. Rationale: Implied consent is limited to life-threatening emergencies and is appropriate when a person is unconscious and/or delusional. B. informed consent. Rationale: Informed consent is when the patient has been told of the specific risks, benefits, and alternative treatments. C. expressed consent. Rationale: Correct answer. It is also know as actual consent. D. emergency consent. Rationale: This does not exist as a form of consent.

34 Review 2. Which of the following is an example of abandonment? A. An EMT-B leaves the scene after a competent adult has refused care. B. An EMT-B transfers care of a patient to an emergency department nurse. C. An EMT-Intermediate transfers care of a patient to an EMT-Paramedic. D. A First Responder is transferred patient care from an EMT-Intermediate.

35 Review Answer: D Rationale: Abandonment occurs when patient care is terminated without the patient’s consent or when care is transferred to a provider of lesser training and level of certification.

36 Review 2. Which of the following is an example of abandonment? A.An EMT-B leaves the scene after a competent adult has refused care. Rationale: Mentally competent adults have the right to refuse treatment or withdraw from treatment at any time. B. An EMT-B transfers care of a patient to an emergency department nurse. Rationale: An EMT-B can transfer care to someone of equal or higher medical authority. C. An EMT-Intermediate transfers care of a patient to an EMT- Paramedic. Rationale: An EMT-I can transfer care to someone of equal or higher medical authority. D. A First Responder is transferred patient care from an EMT- Intermediate. Rationale: Correct answer

37 Review 3. Your unit is the first to arrive at the scene of an injured person. As you approach the residence, you hear screaming and the sound of breaking glass. You should: A. quickly enter the house and provide emergency care. B. retreat to a safe place and notify law enforcement. C. request police assistance and then enter the residence. D. carefully enter the house and identify yourself as an EMT.

38 Review Answer: B Rationale: Never enter a scene when signs of violence (eg, screaming, breaking glass) are present. Retreat to a safe place and notify law enforcement at once. You should enter the scene only after law enforcement have arrived and deemed is secure.

39 Review 3. Your unit is the first to arrive at the scene of an injured person. As you approach the residence, you hear screaming and the sound of breaking glass. You should: A.quickly enter the house and provide emergency care. Rationale: Never enter a scene when signs of violence (eg, screaming, breaking glass) are present. B. retreat to a safe place and notify law enforcement. Rationale: Correct answer C. request police assistance and then enter the residence. Rationale: Never enter a scene when signs of violence (eg, screaming, breaking glass) are present. D. carefully enter the house and identify yourself as an EMT. Rationale: Never enter a scene when signs of violence (eg, screaming, breaking glass) are present.

40 Review 4. Failure of the EMT-B to provide the same care as another EMT-B with the same training is called: A. libel B. slander C. negligence D. abandonment

41 Review Answer: C Rationale: An EMT-B could be held liable for negligence if he or she fails to provide the same care as another EMT-B with the same training provide in the same situation. For example, if an EMT-B fails to give oxygen to a patient with shortness of breath (an intervention that is clearly indicated), he or she may be held liable for negligence.

42 Review 4. Failure of the EMT-B to provide the same care as another EMT-B with the same training is called: A.Libel Rationale: Libel is making a false statement in a written form that injuries a good person’s name. B. Slander Rationale: Slander is verbally making a false statement that injuries a good person’s name. C. Negligence Rationale: Correct answer D. Abandonment Rationale: Abandonment is the abrupt termination of contact with a patient.

43 Review 5. An 8-year-old boy was struck by a car, is unconscious, and is bleeding from the mouth. As you begin to provide care, a police officer tells you that he is unable to contact the child’s parents. You should: A. continue to treat the child and transport as soon as possible. B. cease all treatment until the child’s parents can be contacted. C. continue with treatment only if authorized by medical control. D. only provide airway management until the parents are contacted.

44 Review Answer: A Rationale: The child in this scenario is critically-injured and requires immediate treatment and transport; waiting until his parents are contacted wastes time and increases his chance of a negative outcome. If you are unable to contact a minor’s parents or legal guardian, you should proceed with care based on the law of implied consent.

45 Review 5. An 8-year-old boy was struck by a car, is unconscious, and is bleeding from the mouth. As you begin to provide care, a police officer tells you that he is unable to contact the child’s parents. You should: A.continue to treat the child and transport as soon as possible. Rationale: Correct answer B. cease all treatment until the child’s parents can be contacted. Rationale: If a true emergency exists, then consent is implied. C. continue with treatment only if authorized by medical control. Rationale: If a true emergency exists, then consent is implied. D. only provide airway management until the parents are contacted. Rationale: If a true emergency exists, then consent is implied.

46 Review 6. An advanced directive is: A. a set of specific guidelines that clearly defines the different types of consent. B. a formal list that defines by state law whether a patient has decision-making capacity. C a written document that specifies the care you should provide if the patient is unable to make decisions. D. a verbal order given to you by a dying patient's family regarding whether treatment should be provided.

47 Review Answer: C Rationale: An advanced directive is a written document signed by the patient and a witness that specifies the medical care that should be provided if the patient loses decision-making capacity (ie, he or she is no longer deemed competent).

48 Review 6. An advanced directive is: A.a set of specific guidelines that clearly defines the different types of consent. Rationale: An Advanced Directive specifies the specific care a patient will receive and does not address any type of consent. B. a formal list that defines by state law whether a patient has decision- making capacity. Rationale: An Advanced Directive document has already determined that a patient was competent to make decisions when the document was created and signed. C. a written document that specifies the care you should provide if the patient is unable to make decisions. Rationale: Correct answer D. a verbal order given to you by a dying patient's family regarding whether treatment should be provided. Rationale: An Advanced Directive is a written order that defines the patient’s medical decisions.

49 Review 7. Which of the following patients is competent and can legally refuse EMS care? A. A confused young female who states that she is the president B. A man who is staggering and states that he only drank three beers C. A conscious and alert woman who is in severe pain from a broken leg D. A diabetic patient who has slurred speech and is not aware of the date

50 Review Answer: C Rationale: A patient who is of legal age (18 in most states), is conscious, and is alert to person, place, time, and event, likely has decision-making capacity and can legally refuse EMS care. However, patients who are confused, possibly intoxicated, or delusional are not capable of making a rationale decision; therefore, you should provide care based on the law of implied consent.

51 Review 7. Which of the following patients is competent and can legally refuse EMS care? A.A confused young female who states that she is the president Rationale: You must assess whether this patient’s mental condition is impaired. B. A man who is staggering and states that he only drank three beers Rationale: You must assess whether this patient’s mental condition is impaired. C. A conscious and alert woman who is in severe pain from a broken leg Rationale: Correct answer D. A diabetic patient who has slurred speech and is not aware of the date Rationale: You must assess whether this patient’s mental condition is impaired.

52 Review 8. You are treating a patient with an apparent emotional crisis. After the patient refuses treatment, you tell him that you will call the police and have him restrained if he does not give you consent. Your actions in this case are an example of: A. assault. B. battery. C. negligence. D. abandonment.

53 Review Answer: A Rationale: Unlawfully placing a person in fear of immediate bodily harm (ie, having him restrained) without his consent constitutes assault. Unlawfully touching a person without his or her consent constitutes battery.

54 Review 8. You are treating a patient with an apparent emotional crisis. After the patient refuses treatment, you tell him that you will call the police and have him restrained if he does not give you consent. Your actions in this case are an example of: A.assault. Rationale: Correct answer B. battery. Rationale: Battery is the unlawfully touching of a person. This includes care without consent. C. negligence. Rationale: Negligence is failure to provide the same care that a person with similar training would provide. D. abandonment. Rationale: Abandonment is the unilateral termination of care without the patient’s consent.

55 Review 9. The EMT-B has a legal duty to act if he or she is: A. off duty and witnesses a major care accident. B. a volunteer, is on duty, and is dispatched on a call. C. paid for his or her services, but is not on duty. D. out of his or her jurisdiction and sees a man choking.

56 Review Answer: B Rationale: The EMT-B—paid or volunteer—has a legal duty to act if he or she is on duty and is dispatched on a call, regardless of the nature of the call. If the EMT-B is off duty and/or out of his or her jurisdiction, he or she has a moral obligation to act, but not necessarily a legal one.

57 Review 9. The EMT-B has a legal duty to act if he or she is: A.off duty and witnesses a major care accident. Rationale: This is a moral obligation to act and not a legal one. B. a volunteer, is on duty, and is dispatched on a call. Rationale: Correct answer C. paid for his or her services, but is not on duty. Rationale: Whether paid or volunteer, the EMT-B must be on duty. D. out of his or her jurisdiction and sees a man choking. Rationale: This is a moral obligation to act, and not a legal one.

58 Review 10. Which of the following statements about records and reports is FALSE? A. Legally, if it wasn't documented, it was not performed B. A complete, accurate report is an important safeguard against legal problems C. An incomplete or untidy patient care report is evidence of incomplete or inexpert emergency medical care D. Your patient care report does not become a part of the patient’s hospital record because your treatment was provided outside the hospital

59 Review Answer: D Rationale: One of your most important safeguards against legal problems is a complete, accurate report; if it wasn’t documented, it wasn’t done! Furthermore, an incomplete or untidy patient care report (PCR) suggests incomplete or inexpert medical care. The PCR becomes a part of the patient’s hospital medical record; even though your treatment was provided outside the hospital, the PCR ensures continuity of care in the hospital.

60 Review 10. Which of the following statements about records and reports is FALSE? A.Legally, if it wasn't documented, it was not performed Rationale: True. If it was not written, then it was not performed. B. A complete, accurate report is an important safeguard against legal problems Rationale: True. Most the important safeguard against legal problems is a complete, accurate report. C. An incomplete or untidy patient care report is evidence of incomplete or inexpert emergency medical care Rationale: True. An incomplete or untidy report equals incomplete or inexpert emergency care. D. Your patient care report does not become a part of the patient’s hospital record because your treatment was provided outside the hospital Rationale: Correct answer