1. Medical Legal Nate Green, FF/PM Anchorage Fire Department

2. Objectives  After this presentation you should be able to: Identify common legal terms. Identify common legal terms. Understand who has medical/legal rights and how they obtain them. Understand who has medical/legal rights and how they obtain them. Understand the difference in legal rights. Understand the difference in legal rights. Understand how these medical rights pertain to patient care. Understand how these medical rights pertain to patient care.

3. Power Of Attorney  Creates an agent that gives them authority to make legal decisions and carry them out on your behalf.  Two types: General P.O.A: Covers broad aspects. General P.O.A: Covers broad aspects. Specific P.O.A: Chooses certain aspects that the person wants. Specific P.O.A: Chooses certain aspects that the person wants.  Agents can be immediately recognized or delayed depending on disability.

4. Alaska Laws  Alaska has special additional laws that pertain to addressing health care advance directives.  Health care agents are assigned to make general and specific health care decisions on the patients behalf; i.e., end of life treatment decisions and living wills.

5. Alaska Laws (cont.)  Because someone has a legal P.O.A., it doesn’t necessarily make them a health care agent as well.  Additional provisions regarding health care directives must be filled out by the patient and checked on the P.O.A form.

6. Alaska Advanced Health care Directive  An advance directive allows you to have a say in how you want to be treated if you become very ill. In the document, you can choose a health care agent, choose the kind of health you want, and choose to make an anatomical gift (organ/tissue donation.

7. Living Will  A living will is one type of health care directive. In the document, you can outline the type of care that you want if in the event you become ill. A living will is usually not as detailed as an advance directive.

8. Advance Directives and Living Wills  Can be filled out and created at any point in life. You do not necessarily have to be sick or ill.

9. Advanced Directives  Durable power of attorney for health care.  This essentially creates the designation of an agent to make health care decisions for you.  Gives the agent full control of your health care.  The Alaska Advanced Health Care Directive is broken down into the following 5 parts.

10. Part 1  Consent or refuse any care, treatment procedure to maintain, diagnose, or otherwise affect a physical or mental condition.  Select or discharge health care providers and institutions.

11. Part 1 (cont.)  Approve or disapprove diagnostic test, surgical procedures and medications.  Direct the use of artificial hydration and nutrition and all other forms of healthcare.  Make the decision on anatomical gifts following your death.

12. Sections Continued  Part 2 Gives you specific instructions to dictate how or what care you would like. Gives you specific instructions to dictate how or what care you would like.  Part 3 Lets you express an intention to make an anatomical gifts following your death. Lets you express an intention to make an anatomical gifts following your death.  Part 4 Lets you make decisions in advance about certain types of mental heath treatment. Lets you make decisions in advance about certain types of mental heath treatment.  Part 5 Allows you do designate a physician to have primary responsibility for your health care. Allows you do designate a physician to have primary responsibility for your health care.

13. Advance Directives  You have the right to revoke, advance health care directives or replace the form at any time.  You loose power to revoke when you are deemed incompetent by a court, or by two physicians, at least one whom shall be a psychiatrist.

14. Alaska Comfort One Program  Established into law in 1996.  Helps health care providers identify terminally-ill people who have expressed these wishes.  The program established a protocol for health care providers to respect these wishes once the person has been identified as being enrolled in the program.  DNR Protocol (7 AAC 16.010-7AAC 16.090)

15. Definition of Health Care Provider  Health care provider means a person who is licensed, certified or otherwise authorized or permitted by law to provide health care in the ordinary course of business or practice of a profession.

16. Comfort One  For the purpose of the statue, an individual who is authorized to administer CPR appears to fall within the definition of a “health care provider” in AS 13.52.390(23) with respect to activities related to CPR.  Consequently, even those providers authorized to administer only limited health care must, by statue, respect the Comfort One form,wallet card or bracelet.

17. Comfort One (cont.)  Proof of Enrollment forms. Printed form containing patients name, address, date of birth and gender. Printed form containing patients name, address, date of birth and gender.  To be valid the form must be signed by both a physician and the patient if the patient is able.  Patients generally have the form or two of the other approved pieces of identification of enrollment. Wallet Cards Wallet Cards Bracelets Bracelets

18. Comfort One (cont.)  A DNR may only be revoked by the following people: The patient. The patient. The patient’s physician. The patient’s physician. The parent or guardian of a DNR patient if the patient enrolled in the Comfort One Program is under the age of 18. The parent or guardian of a DNR patient if the patient enrolled in the Comfort One Program is under the age of 18.

19. Comfort One (cont.)  Confirm the patient’s identity in these acceptable manners: Patient can communicate their name. Patient can communicate their name. Identification arm band. Identification arm band. Patient being personally known to physician or other health care provider. Patient being personally known to physician or other health care provider. Patient’s family member(s) on location. Patient’s family member(s) on location. Patient’s driver’s license. Patient’s driver’s license. Dispatch notifies you they have a valid Comfort One on file for that patient/address. Dispatch notifies you they have a valid Comfort One on file for that patient/address.

20. Comfort One (cont.)  Once the patient’s identity and DNR status have been confirmed: If the patient is pulseless and apenic and does not have a valid DNR begin resuscitation efforts. If the patient is pulseless and apenic and does not have a valid DNR begin resuscitation efforts. If the patient does have a valid DNR, resuscitation efforts should not be initiated or if already in progress should be terminated immediately. If the patient does have a valid DNR, resuscitation efforts should not be initiated or if already in progress should be terminated immediately.

21. Patients with Out of State DNR  A DNR order issued in another state, territory or possession of the Unites states is valid if it complies with Alaska law.  A health care provider can presume, in the absence of actual notice to the contrary, that a DNR order and identification is valid, and treat the patient in accordance with the Alaska Comfort One protocol. (AS 13.52.150)

22. AFD Comfort One Policies  When AFD responds to an expected home death or Comfort One patient: EMT or MICP will carefully evaluate pulse and respiration before verbal confirmation of death is reported to APD, AFD dispatch or the patient’s family. EMT or MICP will carefully evaluate pulse and respiration before verbal confirmation of death is reported to APD, AFD dispatch or the patient’s family. ECG is not required nor is it preferred. ECG is not required nor is it preferred.

23. AFD Comfort One Policies (cont.) Physical findings must be documented completely on the patient care report. Physical findings must be documented completely on the patient care report. If the patient still has measurable vital signs and the family requests transport without resuscitation an AFD MICU will transport to a receiving facility. If the patient still has measurable vital signs and the family requests transport without resuscitation an AFD MICU will transport to a receiving facility.

24. AFD Comfort One Policies (cont.) It is the responsibility of the EMT or MICP to assess the needs of the family for emotional support and ascertain whether logistical assistance in dealing with the deceased is required. It is the responsibility of the EMT or MICP to assess the needs of the family for emotional support and ascertain whether logistical assistance in dealing with the deceased is required. Chaplain may be contacted through AFD dispatch to assist the family or caregivers of the patient at the discretion of the EMT or MICP. Chaplain may be contacted through AFD dispatch to assist the family or caregivers of the patient at the discretion of the EMT or MICP.

25. AFD Comfort One Policies (cont.) Comfort One expected home deaths, with valid DNR orders on scene or on file with dispatch, and after confirmation of death and proper notifications have been made it is permissible to leave the patient with the family. Comfort One expected home deaths, with valid DNR orders on scene or on file with dispatch, and after confirmation of death and proper notifications have been made it is permissible to leave the patient with the family.

26. Law Enforcement Response  In the event of an expected home death with valid DNR paperwork APD is not required to respond.  In the event something on scene seems suspicious with the death an APD officer should be requested.

27. Law Enforcement Response (cont.)  Title 12. Code of Criminal Procedure  Chapter 12.65. Death investigations and Medical examiners. Section 12.65.007.

28. Law Enforcement Response (cont.)  A peace officer is not required by state law to respond to the scene of an expected home death if: The death was expected to occur due to the deceased state of health before death. The death was expected to occur due to the deceased state of health before death. The death occurred at the deceased’s home as expected due to the deceased’s state of health. The death occurred at the deceased’s home as expected due to the deceased’s state of health.

29. Law Enforcement Response (cont.)  A person authorized to determine and pronounce death determines and pronounces the death: A form signed by the deceased’s physician concerning the physician's expectation that the death would occur due to the person's state of health and that it would occur at home was, at the time of death, on file with the law enforcement agency for that jurisdiction. A form signed by the deceased’s physician concerning the physician's expectation that the death would occur due to the person's state of health and that it would occur at home was, at the time of death, on file with the law enforcement agency for that jurisdiction.

30. Law Enforcement Response (cont.)  When Law enforcement does need to respond.: 11-29 Expected Home death when no DNR is available or patient is not under hospice. 11-29 Expected Home death when no DNR is available or patient is not under hospice.  Often this happens when people either forget to fill out the paperwork, never fill out the paperwork or the death happens very suddenly or quicker than expected.

31. Hospice Care  Program that provides comfort care at the end of life through intensive symptom management, and support of patient/family identified goals of care.  Hospice care for adults with a life limiting illness and prognosis of less than six months. The goal is to improve the quality of life for the patient and family.

32. Hospice Care (cont.)  Hospice patients are generally Comfort One patients and do not require transport to the ED unless an health care agent requests this.  Generally if the hospice nurse is not on location of a scene contacting them is easy and very valuable to the health care provider in the event you need questions answered.

33. Alaska MOST  Medical Orders for Scope of Treatment  Generally at the Pioneer Home and similar facilities.  If applicable, have company officer or other healthcare provider ask for MOST form. Continue treatments as indicated on the form.  Breaks down treatment options into 4 simple categories.

34. Alaska MOST (cont.)  Treatment Section A.  Treatment options when the person is not breathing and has no pulse Do Not attempt Resuscitation. Do Not attempt Resuscitation. Attempt Resuscitation/CPR. Attempt Resuscitation/CPR.

35. Alaska MOST (cont.)  Treatment Section B: Treatment options when the person has a pulse and is breathing. Comfort Measures Only: Medication, positioning and other measures to relieve pain and suffering. Use oxygen, suction and manual treatment of airway obstruction as needed for comfort. Comfort Measures Only: Medication, positioning and other measures to relieve pain and suffering. Use oxygen, suction and manual treatment of airway obstruction as needed for comfort.  Do not transport for life sustaining treatment.  Only transport if comfort needs cannot be met at current location.

36. Treatment Section B (cont.)  Limited Interventions: Use care above as well as medical treatment, IV and cardiac monitor as appropriate. Transfer to ED if appropriate. These patients avoid ICU if possible.  Trial of Intensive Therapy. Includes care above including trial of intubation, ventilator.  Full treatment. ACLS,Intubation,Ventilation cardioversion etc.

37. Treatment Sections C and D  Last two items not in the scope of EMS.  Relates to antibiotic use and artificial nutrition.

38. AFD Policies  Obvious Death/Decision Not to resuscitate.  First arriving crew to begin resuscitation on any patient without pulse or respirations unless one or more of the following signs are present.  If there is ANY DOUBT whether or not the patient meets this criterions, then CPR with BLS adjuncts shall be initiated.

39. AFD Policies  Resuscitative efforts shall continue until the first arriving MICP or EMT determines that the patient is beyond resuscitation and/or an emergency department physician is contacted and consulted.

40. Criteria #1  Evidence of a non-recent death.  Rigor Mortis-Caused by chemical changes to the muscle after death causing the muscles to stiffen. This is only valid if hypothermia is not a factor.  Dependent Lividity-settling of the blood in dependent portion of the body resulting in a purplish red discoloration of the skin.  Any evidence of decomposition.

41. Criteria # 2  Explosive gunshot wound or wounds to the head.

42. Criteria # 3  Severe injury obviously incompatible for life.

43. Criteria #4  Submersion greater than one hour.

44. Criteria 5  Suspected death due to hypothermia with the following signs: Core Temp<60 degrees. Core Temp<60 degrees. Patient has ice in the airway. Patient has ice in the airway. Generalized total body frozen skin/tissue which is more than localized frostbite. Generalized total body frozen skin/tissue which is more than localized frostbite.

45. Procedure  First arriving unit determines patient is beyond resuscitation and notifies dispatch person is 11-29.  First arriving EMT/MICP will confirm initial assessment and gather information for paperwork and report.  Life Alaska information will be gathered and phoned to dispatch.

46. Exceptions to this policy  Triage decisions in multi patient incidents.  Inability to gain access to the scene or patient. Entrapment Entrapment Law Enforcement will not allow access. Attempt to get badge number/name of officer. Law Enforcement will not allow access. Attempt to get badge number/name of officer. Situations that would place rescuers/AFD personnel in grave danger. Situations that would place rescuers/AFD personnel in grave danger. Decisions based upon direct consultation with an emergency room physician, or with an identified MD on scene. Delays in Physician contact must be fully documented. Decisions based upon direct consultation with an emergency room physician, or with an identified MD on scene. Delays in Physician contact must be fully documented.

47. Documentation  The first arriving MICP or EMT shall complete a patient care report, specifically recording the physical findings which support the decision not to resuscitate based on the criteria established in this policy.  Document any consultations with ED with time and name of MD spoken with.

48. Patients Unresponsive to CPR  Decisions to discontinue advanced life support resuscitation measure in the field once underway require consultation with an emergency room physician.  Document time, whom you spoke to and hospital in the PCR.

49. Traumatic Cardiac Arrests  Resuscitation efforts should be withheld in victims of penetrating or blunt trauma with injuries obviously incompatible with life Decapitation. Decapitation. Hemicorporectomy. Hemicorporectomy. Significant time lapse since pulselessness. Significant time lapse since pulselessness.

50. Blunt Trauma  Resuscitation efforts may be withheld in any blunt trauma patient who, based upon a MICP’s thorough primary patient assessment, is found: Pulseless and apneic. Pulseless and apneic. Asystolic in ECG Leads I,II, III. Asystolic in ECG Leads I,II, III.

51. Penetrating Trauma  Resuscitation efforts may be withheld in any penetrating trauma patient who, based upon a MICP’s thorough primary patient assessment, is found: Pulseless and apneic. Pulseless and apneic. Absence of papillary reflexes or spontaneous movement. Absence of papillary reflexes or spontaneous movement. Asystolic in ECG leads I,II,III. Asystolic in ECG leads I,II,III.

52. Traumatic Arrests  Cardiopulmonary arrest patients in whom the mechanism of injury does not correlate with clinical condition, suggesting a non- traumatic cause of the arrest, should have standard resuscitation initiated.

53. Traumatic Arrests  Termination of resuscitation efforts should be considered in trauma patients with EMS- witnessed cardiac arrest and 15 minutes of unsuccessful resuscitation and CPR.  Traumatic cardiac arrest patients with a transport time to an emergency department of more than 15 minutes after the arrest is identified may be considered non-salvageable, and termination of resuscitation should be considered.

54. SUID (Sudden Unexpected Infant Death)  Policy  In recognition of CDC guidelines concerning death scene investigation for victims of SUID it shall be the policy of the Anchorage Fire Department not to transport those patients under twelve months of age believed to have expired as a result of sudden infant death syndrome in circumstances when no resuscitation efforts have been undertaken.