2 Legal and Ethical Principles of Emergency Care

Objectives Define the following terms: Abandonment Advance directive Battery Breach of duty Civil law (tort) Competence Competent Confidentiality continued on next slide

Objectives Define the following terms: Consent Criminal law Duty Duty to act Emancipated minor Ethics Expressed consent continued on next slide

Objectives Define the following terms: Good Samaritan law Health Insurance Portability Accountability Act (HIPAA) Implied consent Informed consent Mandated reporter continued on next slide

Objectives Define the following terms: Negligence Standard of care Unresponsive Values continued on next slide

Objectives Explain the concepts of "duty" and "breach of duty" as they relate to the Emergency Medical Responder. Explain the term ethics and how it relates to the Emergency Medical Responder. Explain the term Good Samaritan law and how these laws relate to the Emergency Medical Responder. continued on next slide

Objectives Explain the term mandated reporter and how it relates to the Emergency Medical Responder. Differentiate the terms scope of practice and standard of care. Compare and contrast the various types of consent utilized by the Emergency Medical Responder. continued on next slide

Objectives Explain the role of the Emergency Medical Responder for patients who refuse care. Differentiate civil and criminal litigation. Explain the common elements of an advance directive. continued on next slide

Objectives Explain the role of the Emergency Medical Responder when confronted with an advanced directive. Explain the role of the Emergency Medical Responder with regards to patient confidentiality. continued on next slide

Objectives Explain the role of the Emergency Medical Responder with respect to evidence preservation when working in or around an actual or potential crime scene. Consistently model ethical behavior in all aspects of Emergency Medical Responder training and job performance. continued on next slide

Objectives Demonstrate compassion and empathy toward all classmates, coworkers, and simulated patients. Participate willingly as a team member in all class/training activities. Value the importance of maintaining patient confidentiality. Demonstrate a desire to always do what is right for the patient.

Topics Legal Duties Consent Advance Directives Negligence Abandonment Confidentiality Reportable Events Special Situations

LEGAL DUTIES

Legal Duties Good Samaritan laws Duty Minimize exposure to liability Encourage bystanders to provide emergency care No compensation Remain within scope of practice Duty Moral and legal obligation to provide care Talking Point: EMRs may have a legal and/or ethical duty to assist those in need. Discuss your state's laws/regulations that apply to the EMR's duty to act. continued on next slide

Legal Duties Scope of Practice What is legally permitted to be done by individuals trained or licensed at a particular level Does not define what must be done for patient or in a particular situation Based on EMS education standards Discussion Question: What is the approved scope of practice for EMR in your state or region? continued on next slide

Legal Duties Standard of Care Varies from county to county, state to state, region to region Based on level of training and experience working under similar conditions Expected to follow approved standing orders/protocols for your EMS system Teaching Tip: Provide handouts and/or website links to local protocols, state EMS laws, and regulations.

Figure 2.1 Different emergency personnel may be assisting during an emergency, including police, firefighters, and EMTs. Each must practice the standard of care expected of his own level of training. (Mark C. Ide/CMSP)

Legal Duties Ethics Study of principles that define behavior as right, good, and proper EMS values Integrity Compassion Accountability Respect Empathy Discussion Topic: Share additional resources that might help an EMR clearly understand difficult legal and ethical issues. continued on next slide

Legal Duties Ethical Responsibilities Patient's needs before responder's own, so long as safe to do so Patient receives appropriate medical care. Maintain an open mind. Critical Thinking: EMRs may find ethical challenges based on conflicts with their own beliefs and that of their patients. How can the EMR cope with these differences while still treating patients equally? continued on next slide

Legal Duties Ethical Responsibilities Develop understanding of differences. Treat all people equally. Provide the highest standard of care. Maintain and practice skills and knowledge. Attend continuing education. continued on next slide

Legal Duties Ethical Responsibilities Be honest in reporting care provided. Errors should be reported immediately. Values are core beliefs that you hold to be true. Class Activity: Invite a local attorney to discuss medical-legal issues.

Think About It How can understanding legal/ethical issues help the EMR make better decisions? How does scope of practice and standard of care differ? How can embracing ethical values help the EMR serve as a better patient advocate?

CONSENT

Consent Legal term for giving formal permission for something to happen EMRs must receive permission from patients before legally providing care.

Consent Competence Being adequately or well qualified to make decisions both physically and intellectually Critical Thinking Discussion: You respond to a home where a 40-year-old man appears to be intoxicated. His wife reports that he has been slurring his words and is not acting appropriately, but he adamantly refuses examination. What do you do?

Consent Patient may not be competent to make medical decisions. Being a minor Intoxication Drug ingestion Serious injury Mental illness Critical Thinking Discussion: You respond to a home where a 40-year-old man appears to be intoxicated. His wife reports that he has been slurring his words and is not acting appropriately, but he adamantly refuses examination. What do you do?

Consent Expressed Consent Competent adult's informed decision to accept emergency care provided by an EMR (informed consent) By law, only a parent or guardian of a child may give consent or refuse care. Discussion Question: Can you think of times when it may be difficult to obtain parental consent for care? continued on next slide

Consent Expressed Consent Advise patient of: Your level of training Why you think care may be necessary What care you plan to provide Any consequences related to refusing care Talking Point: Keeping patients informed is not only part of your duty as an EMR; it also helps to alleviate patient anxiety.

continued on next slide Figure 2.2a Once the scene is safe, you must obtain consent to care for the patient. continued on next slide

Figure 2.2b Always show respect when obtaining consent.

Consent Implied Consent Legal position assumes that unresponsive or incompetent adult patient would consent to receiving emergency care if he/she could. Law assumes parents would want care to be provided for their child. Critical Thinking Discussion: You respond to a school bus accident involving six (6) children. The parents and guardians are not on scene. What do you do?

Figure 2.3 Implied consent is used when the patient is a minor.

Consent Emancipated Minor Legally allowed to make their own decisions regarding medical care Married Pregnant Parent Member of armed forces Financially independent Living away from home Critical Thinking Discussion: You and your partner are called to evaluate a 16 year-old involved in a minor MVC that has occurred after "running away from home." The child has no injuries; but when you contact the parents by phone, they say that the child is not welcome at home and they refuse to pick him up. Discuss your options.

Consent Refusal of Care Alert and competent adults have the right to refuse care. Restraining or threatening to restrain patient against his/her wishes could result in violation of criminal law. Parent/legal guardian can refuse to let you care for a child. Critical Thinking Discussion: You have responded to the scene of an accident where a patient who appears to be competent and moderately injured is refusing care, citing financial reasons. Family members on scene insist on treatment. What do you do? continued on next slide

Consent Refusal of Care When care is refused Stay calm and professional. Inform patient of potential dangers of refusal. Use aid of someone the patient trusts. Carefully document refusal of care. Class Activity: Direct students to work in groups of four (4) to role-play an emergency situation where a patient refuses care. Assign two EMRs, one patient, and a patient's family member. Follow-up with a discussion about what worked well and what could be improved.

Think About It What must the EMR receive from a patient in order to provide care? How can the EMR determine competence of a patient to refuse care? EMRs must not leave a patient refusing care until someone with higher training assumes care.

ADVANCE DIRECTIVES

Advance Directives Document that allows a patient to define in advance what an individual wishes are in the case of becoming incapacitated due to medical illness or severe injury Talking Point: In some states, Advance Directives may be referred to by other names, such as health-care proxies, living wills, or physician ordered life-sustaining treatment (POLST). Discuss the differences in the types of advance directives in your state.

Advance Directives Designation of agent to make decisions on your behalf Do Not Resuscitate (DNR) order Choice to prolong or not prolong life Pain relief options Donation of organs Class Activity: Provide a copy of an advance directive and the associated regulations for your state (review/discuss). Have students complete the form and discuss it with their families. Discuss the results as a group.

Advance Directives Do Not Resuscitate (DNR) Orders Written legal document, signed by patient and physician States patient has terminal illness and does not wish to prolong life through resuscitative efforts Does not mean "do not care" Talking Point: In some states, a DNR may not be limited to patients with terminal illness. It may also be in place for those with long-term illnesses who do not want resuscitative efforts initiated.

Figure 2. 4 A DNR order is one example of an advance directive Figure 2.4 A DNR order is one example of an advance directive. Other examples include POLSTs and living wills.

Think About It What is the benefit of having an Advance Directive? EMRs must be familiar with their state's regulations and forms in use. You respond to a nursing home where an elderly female is having difficulty breathing. She has a valid DNR. Is it acceptable to withhold oxygen? Class Activity: Divide the class into two groups. Assign one of the following scenarios to each group. Have each group discuss how they would manage the situation and then choose a group leader to share the results with the whole class. Scenario #1: You respond to a nursing home for an 89-year-old bone cancer patient in cardiac arrest. The staff is certain that the patient has a do not resuscitate (DNR) order, but no one can find the actual order. Scenario #2: You respond to a patient in cardiac arrest. The patient has a living will that requests no resuscitation, but your state does not honor living wills. The family does not want any care provided.

NEGLIGENCE

Negligence Failure to provide expected standard of care Four elements to determine negligence Duty to act Breach of duty Damages Causation Teaching Tip: Use media article examples about civil action against health care providers to put negligence in the context of real-life situations.

Negligence EMRs have a legal duty to act. A legal duty to act has been established if care is offered and accepted by the patient. Provide care according to agency's standard operating procedures. Laws vary from state to state. Discussion: Compare and contrast the roles of bystander, volunteer, and paid personnel.

Negligence General rule Advise patient to accept treatment by EMTs. State "Good Samaritan" laws may offer protection from civil liability. Be familiar with your own state's laws. Talking Point: Discuss the "Good Samaritan" laws for your state. Some states limit this protection to lay-rescuers who do not legally have a duty to act.

Think About It What are the four elements required to prove negligence? By what standard will the EMR be judged?

ABANDONMENT

Abandonment To leave sick or injured patient before equal or more highly trained personnel can assume responsibility for care Could include failure to provide patient information during transfer to more highly trained personnel Facts gathered Assessment findings Care rendered Teaching Tip: Provide examples of emergency situations which could lead to EMRs being charged with abandonment.

Figure 2.5 Once care is initiated, the Emergency Medical Responder assumes responsibility for the patient until relieved by more highly trained personnel.

Think About It You are on scene with an adult who has fallen and is complaining of only ankle pain. The ambulance has not arrived yet. A "child not breathing" call is dispatched in your immediate vicinity but the other EMR unit responding is across town. What do you do?

CONFIDENTIALITY

Confidentiality Treatment of information that individual has disclosed in relationship of trust and with expectation that it will not be divulged to others Protect the patient's right to privacy. Information only released if patient has authorized to do so in writing Talking Point: EMRs do not speak to family, friends, neighbors, or the public about any patient, including whether the patient received care.

Confidentiality Authorization not required for you to pass on patient information to other health care providers Health Insurance Portability and Accountability Act (HIPAA) gives patients more control over their health care information and limits ways that information is stored and shared. Teaching Tip: Provide access to the HIPAA standards. Discussion Question: What is the public's "right to know" in cases where a patient's care may be related to public health? (e.g., a highly contagious disease) How does the EMR handle these requests for information?

Figure 2.6 To maintain patient confidentiality, discuss your patient with only those who will be continuing patient care.

Figure 2.7 You must provide an accurate report to the EMS team who will be taking over care of the patient.

Think About It How might an EMR unwittingly reveal confidential information? You respond to a duplex where a 30-year-old male appears to have over-dosed. The EMTs arrive on scene and assume care. The patient's parents who live next door enter the room and ask you what happened. What do you tell them?

REPORTABLE EVENTS

Reportable Events All 50 states have laws that define mandatory reporters and what types of events they must report. May include: Exposures to infectious diseases Suspicious burns Vehicle crashes Drug-related injuries Teaching Tip: Provide your state's mandatory reporting regulations and forms. Discuss the proper way to complete each report.

Reportable Events May include: Crimes resulting in knife or gunshot wounds Child and elder abuse Domestic violence Rape Class Activity: Invite a children's protective service, elder affairs employee, or police officer to speak to the class about what happens after a report is filed by an EMR.

Think About It Understand the reporting requirements for your state. Keep report forms and phone numbers needed in a readily available location. Do not assume someone else on scene will handle the report.

SPECIAL SITUATIONS

Special Situations Organ Donors Patient completed legal document that allows for donation of organs and tissues in event of death. Care must not differ in any way from care of patient who is not a donor. Oxygen delivered to body cells by CPR will help preserve the organs. Talking Point: It is not always possible to know if a patient is an organ donor. Hospital staff will validate patient's wishes.

Special Situations Medical Identification Devices Necklace, arm/ankle bracelet, or card meant to alert EMS personnel that patient has particular medical condition Such as a heart problem, allergies, diabetes, epilepsy May provide important medical information Talking Point: Be sure to indicate medical identification information to EMTs when transferring patient care. continued on next slide

Special Situations Medical Identification Devices Some areas use "Vial of Life" program. Special vial where important medical information is stored. Window sticker alerts EMS to vial kept in patient's refrigerator. Teaching Tip: In some areas, a File of Life program is in use where information (health history, medications, and allergies) is stored in a vinyl sleeve that contains a magnet to put on the refrigerator. Provide samples of the program devices in use in your area so EMRs know what to look for.

Figure 2.8 The MedicAlert bracelet is one example of a medical identification device.

Special Situations Crime Scenes Location where crime has been committed or place where evidence relating to crime may be found. Do not enter scene until instructed to do so by law enforcement. Make as little impact on scene as possible to preserve evidence. Teaching Tip: Invite a crime scene police officer to discuss crime scene preservation.

Think About It Organ donors receive the same care as those who are not donors. True or False? Aside from medical alert tags, where else might you find health information? Minimize impact on crime scenes (e.g., touch/move little, don't cut through holes in clothing from GSW or stabbing).

SUMMARY

Summary Legal duty to provide care and must do so within scope of practice Must maintain high degree of integrity as well as ethical and moral standards when caring for patients Have a responsibility to keep both knowledge and skills up-to-date continued on next slide

Summary Must obtain consent from every victim and be able to apply principles of expressed and implied consent Properly manage and document all patients who refuse care and enlist law enforcement when necessary. continued on next slide

Summary Could be accused of negligence if you do not provide acceptable level of care or if you abandon patient Must respect privacy and confidentiality of all patients and refrain from sharing information about patients unless legally allowed or required to do so

REVIEW QUESTIONS

Review Questions Explain the concepts of: Duty to act Breach of duty Ethics What is the difference between scope of practice and standard of care? How does the Good Samaritan law in your area relate to the EMR? continued on next slide

Review Questions What is the difference between civil and criminal litigation? What are the different types of consent? continued on next slide

Review Questions Explain the role of the EMR with regard to: Refusal of care Advance directives Patient confidentiality Mandated reporting Crime scene preservation

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