1. Legal and Ethical Issues
Chapter 4

2. 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.

3. 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

4. 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.

5. 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)

6. 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

7. 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.

8. 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

9. 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

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

11. 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

12. 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

13. 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

14. 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

15. 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.

16. 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

17. 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

18. 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

19. Legal Considerations
In Texas an assault is comparable crime under the Texas Penal Codes.
CHAPTER 22. ASSAULTIVE OFFENSES
Sec 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

20. 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.

21. 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

22. 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

23. 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

24. 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

25. 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

26. 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.

27. 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