Consent The granting of permission to treat a patient. You must have consent before treating a patient. Patient must be competent to give or withhold consent.

Types of consent Expressed (Informed) Implied

Informed Consent Consent based on full disclosure of the nature, risks, & benefits of a procedure. Must be obtained from every competent adult before treatment. In most states, a patient must be > 18 years of age to give/withhold consent. In general, a parent or guardian must give consent for children.

Expressed Consent Verbal, nonverbal, or written communication by a patient who wishes to receive treatment. The act of calling for EMS is generally considered as an expression of the desire to receive treatment. You must obtain consent for each treatment provided.

Expressed Consent Must be obtained from every conscious, mentally competent adult. A mentally competent adult is older than the legal age & able to make an informed decision For the consent to be informed, the patient must be made aware of all risks, benefits, & consequences of the care provided and any alternatives to care A patient must express their consent verbally or with affirmed gesture

Implied Consent Refers to circumstances where verbal or written consent is not possible but considers that a reasonable person would want & expect ER treatment to be rendered

Implied Consent Consent for treatment that is presumed for a patient who is mentally, physically, or emotionally unable to give consent. It is assumed that a patient would want life-saving treatment if able to give consent. Also called ER doctrine.

True ER True ER: exists when a person will either die or have a permanent injury if not treated immediately Consent is considered implied; the person, if awake or able, would want care Can be used with children under 18

Special Consent Situations Minors ( Usually a person < 18 years of age ). Consent must be obtained from a parent or legal guardian. Mentally incompetent adult Consent must be obtained from the legal guardian.

Special Consent Situations For minors & mentally incompetent adults... If a parent or legal guardian cannot be found, treatment may be rendered under the doctrine of implied consent.

Minors & Consent Parent or legal guardian gives consent. In some states, a minor can give consent. Depending on age & maturity Emancipated minors (married, armed services, parents) Teachers & school officials may act in place of parents.

Minors & Consent If true ER exists, and no consent is available: Treat the patient. Consent is implied.

Involuntary Consent Consent for treatment granted by a court order. Most commonly encountered with patients who must be held for mental- health evaluation or as directed by law enforcement personnel who have the patient under arrest. May be used on pts whose disease threatens a community at large.

Emancipated Minor Person < 18 years of age who is: Married Pregnant A parent A member of the armed forces Financially independent living away from home Emancipated minors may give informed consent.

Withdrawal of Consent A patient may withdraw consent for treatment at any time, but it must be an informed refusal of treatment.

Refusals Conscious, alert adults with decision-making capacity: Have the right to refuse treatment Can withdraw from treatment at any time Even if the result is death or serious injury Places burden on EMT to clarify need for treatment If EMS providers touch & provide ER care to a patient without consent, they leave themselves open to charges of assault & battery

Refusals Before you leave a scene where a patient, parent, or caregiver has refused care: Encourage them again to allow care. Ask them to sign a refusal of care form. Document all refusals on a patient care report form. A witness is valuable in these situations.

An example of a “Release-from-Liability” form

Refusal of Service Not every EMS run results in the transportation of the patient to the hospital. ER care must always be offered to the patient, no matter how minor the injury or illness.

If a Patient Refuses (1 of 4) Is the patient legally permitted to refuse care? Make multiple, sincere attempts to convince the patient to accept care.

If a Patient Refuses (2 of 4) Make sure the patient is informed in his or her decision. Consult with on-line medical direction.

If a Patient Refuses (3 of 4) Have the patient & a disinterested witness sign a release-from-liability form. Advise the patient he or she may call again for help.

If a Patient Refuses (4 of 4) Attempt to get someone to stay with the patient. Document the entire situation thoroughly.

Some EMS systems have checklists for procedures to follow when a patient refuses care.

Bledsoe et al., Essentials of Paramedic Care: Division 1 © 2007 by Pearson Education, Inc. Upper Saddle River, NJ Legal Complications Related to Consent

Legal Complications Related to Consent (1 of 4) Abandonment The termination of the paramedic- patient relationship without assurance that an equal or greater level of care will continue

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

Legal Complications Related to Consent (2 of 4) Assault Act of unlawfully placing a person in apprehension of immediate bodily harm without his or her consent Battery The unlawful touching of another person without his or her consent

Legal Complications Related to Consent (3 of 4) False imprisonment The intentional & unjustifiable detention of a person without his or her consent or other legal authority

Legal Complications Related to Consent (4 of 4) Reasonable force The minimal amount of force necessary to ensure that an unruly or violent person does not cause injury to himself, herself, or others

Advanced Directives Advance directives specify treatment should the patient become unconscious or unable to make decisions. A do not resuscitate (DNR) order is an advance directive that gives permission not to resuscitate. “Do not resuscitate” does not mean “do not treat.”

DNR Must Contain Name of patient Name and signature of physician Effective date The words “Do Not Resuscitate” Evidence of consent Signature of patient Signature of legal guardian Signature of POA (Power of Attorney)

Revocation -DNR If the order is physically destroyed or verbally rescinded by the physician who signed the form or person who gave written informed consent to the order (Patient, or POA) A member of the immediate family is present and requests initiation of resuscitation contrary to the written order When in doubt call home…

Living Will Illinois law allows terminally ill patients to instruct their health care provider on their treatment in near death experiences Technical requirements make these documents impractical in the field and are not honored in the field

Power of Attorney A legal document signed by the patient that names a specific person to act on behalf of the patient in making medical decisions, should the patient not be able to do so If the patient is alert & able to communicate, the healthcare agent has no authority

Malpractice Suits

Burns: from hot water, heating pads, lights, malfunctioning equipment, too strong solutions, showers, baths Falls: out of bed, while ambulating, due to wet floors, defective equipment, over-sedation Failure to observe & take appropriate action: refusing to answer call lights, orthopedic injuries, not taking VS, leaving patients alone Examples for Malpractice Suits

Medication & injection errors Dispensing meds as an EMT Mistaken identity: meds, procedures, surgery Failure to communicate: not informing MD of patient problems; poor shift reports; inability to reach MD Abandonment: leaving alone a patient who should not be left alone—double shifts?

Examples for Malpractice Suits Loss or damage to patient property: dentures, clothing, hearing aids Things left in patients during surgery: res ipsa loquitur— the thing speaks for itself Lack of informed consent: permission must be Voluntary (no coercion) Informed (person must clearly understand choices & what is to be done) Physician’s job to get informed consent

Legal Concepts Good Samaritan law: written to encourage healthcare professionals to help in ER situations Reduces the professional liability when responsible care is used Care given must be in the professional’s scope of practice & training Rests on the concept of “implied consent”

Legal Concepts Statute of limitation: a time period after which a malpractice suit cannot be filed Generally 2 years after the discovery of injury In children, up to age 21

Legal Concepts Expert witness: a person called to provide special information or opinions in cases that require special study or experience Usually an instructor, physician, or nursing supervisor, EMT… Can give opinions—usually testimony only allows facts

Suit-Prone Patients Very demanding Very critical of all aspects of the care experience Very dependent Critical of other EMTs Has filed a lawsuit before

Suit-Prone HCPs Insensitive to patient needs Undereducated Overconfident Authoritarian Inflexible

Protection Against Lawsuits Maintain good medical records Establish good relationships with patients Keep your skills current Assess the patient frequently for changes Maintain professional manner Avoid making statements that may admit fault

Protection Against Lawsuits Don’t criticize other professionals Stay within your scope of practice Be definite about instructions Take extra precautions with telephone orders Monitor the care of those you supervise Check the condition of healthcare equipment you are using

Protection Against Lawsuits If in doubt, stop! Watch for adverse outcomes (medications, treatments, etc.) If you suspect a lawsuit, notify your insurance carrier immediately Never tell a patient you have malpractice insurance If a suit is filed, don’t talk to anyone but your lawyer

Malpractice Insurance Two types of policies: Claims-made: protect you only while your policy is in effect Can purchase “tails” that expand the policy Usually a little cheaper Occurrence policies: protect against any claims that occurred during the policy period no matter when it was made