1. Mosby items and derived items © 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc. Legal and Ethical Issues

2. Mosby items and derived items © 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc. Outline Types of Questions Scope of Practice Consent Refusals Advance Directives and DNR Orders Assault and Battery Abandonment Negligence Confidentiality Crime Scene Preservation Documentation

3. Mosby items and derived items © 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc. Legal Questions What legal questions do you have regarding providing emergency care for patients? ?

4. Mosby items and derived items © 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc. Scope of Practice Scope of practice refers to the skills and practices permitted and expected according to state statutes or administrative rules Creates legal and ethical obligations to: –The patient –The medical director –The public

5. Mosby items and derived items © 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc. Legal Duties Providing for the well being of the patient by giving care as defined by the scope of practice –Defined by law –Referenced to the U.S. DOT NSC –Administered through medical oversight

6. Mosby items and derived items © 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc. Legal Duties Responsibility to the medical director

7. Mosby items and derived items © 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc. Ethical Duties Making the needs of the patient a priority Practicing skills to the point of mastery Attending continuing education courses Reviewing personal performance and systems issues Honest reporting

8. Mosby items and derived items © 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc. Consent A patient must consent to medical care, even in an emergency In situations where a patient cannot consent, there are legal provisions for treating the patient

9. Mosby items and derived items © 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc. What is Competence? A patient may only give consent to care or refuse medical care if he or she is competent

10. Mosby items and derived items © 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc. Determining Competence Competence to consent to (or refuse) care by is determined by asking questions to evaluate the patient’s understanding of the situation and the consequences of his or her decisions

11. Mosby items and derived items © 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc. Determining Competence In some cases it is difficult to know whether a patient is competent –Intoxication –Drug use –Serious injury or illness –Mental incompetence

12. Mosby items and derived items © 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc. Types of Consent Expressed consent Implied consent Consent for minors and mentally incompetent adults

13. Mosby items and derived items © 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc. Expressed Consent Must be obtained from all responsive, mentally competent adults before providing emergency care –Identify yourself and level of training –Explain what you are going to do –Explain the risks and benefits

14. Mosby items and derived items © 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc. Implied Consent Applies when a patient is unconscious or otherwise incompetent to consent and needs emergency care Laws assume that if the patient were able to, he or she would consent to care

15. Mosby items and derived items © 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc. Minors and Incompetent Adults Parent or legal guardian must give consent If parent or legal guardian unavailable, implied consent applies in an emergency Some minors may be emancipated

16. Mosby items and derived items © 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc. Right to Refuse A competent patient has the right to refuse care, even if the EMS provider disagrees with the patient’s decision –If competence is doubtful, err in favor of providing care A patient who has consented may change his or her mind or refuse certain aspects of care

17. Mosby items and derived items © 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc. Informed Refusal The EMS provider must ensure the patient has the information to make an informed decision –The patient must be fully informed of the risks of refusing care

18. Mosby items and derived items © 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc. Higher Level of Care on the Way If a more highly trained EMS provider is not yet on scene and a patient is refusing care: –Try to persuade the patient –Find out why patient is reluctant to receive care –Try to ascertain patient competence –Inform patient why it is important to receive care and what may happen if care is not received –Consult medical control –Consider the assistance of law enforcement

19. Mosby items and derived items © 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc. DOCUMENT REFUSALS!

20. Mosby items and derived items © 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc. Advanced Directives and DNRs What’s the Difference? Advance Directive –Living Will –Generally cannot be honored in prehospital setting

21. Mosby items and derived items © 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc. Do Not Resuscitate (DNR) Signed and dated by patient’s physician May be honored (depends on protocol) Do-Not- Resuscitate Order Attending Physician’s Order Authorized Decision- maker Patient’s Signature

22. Mosby items and derived items © 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc. Assault and Battery Claims that may be made against an EMS Provider by a patient Assault –Threat of harm Battery –Unlawful touching

23. Mosby items and derived items © 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc. Abandonment Terminating medical care without transferring the patient to a healthcare provider trained at the same level or higher

24. Mosby items and derived items © 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc. Negligence Deviating from the accepted standard of care, and that act results in harm to the patient

25. Mosby items and derived items © 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc. Components of Negligence Four components are needed –Duty to act –Breach of duty –Injury or damages occurred –Proximate cause

26. Mosby items and derived items © 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc. Think about it… You are off duty at a grocery store and witnesses an elderly man fall in the parking lot –Assume that by state law there is no duty to act Do you have an ethical duty to act? Is there a moral duty to act? What defense do you have for your answer?

27. Mosby items and derived items © 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc. Legally and ethically, a healthcare provider must maintain confidentiality

28. Mosby items and derived items © 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc. Confidential Information Patient medical history information Assessment findings –Types of injuries Care rendered to the patient

29. Mosby items and derived items © 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc. Release of Information May be released only if: –The patient has signed a written release form –Other healthcare providers need the information to continue patient care –Required reporting (i.e., rape, child abuse) –There is a court order

30. Mosby items and derived items © 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc. Crime Scenes If there is a potential crime scene and law enforcement is not on the scene: –Notify dispatch to contact law enforcement –Do not enter the scene if it is not safe or if you do not know if it is safe

31. Mosby items and derived items © 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc. Crime Scene Preservation While caring for the patient, when possible, avoid: –Disturbing or touching any item at the scene –Cutting through holes or tears in clothing Observe and document anything unusual at the scene

32. Mosby items and derived items © 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc. Documentation Making a record of the events of a call –It is a basic responsibility of EMS providers Each state and agency has its own requirements for documentation of calls

33. Mosby items and derived items © 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc. Documentation Basics Completed anytime you respond to a call –Regardless of patient contact Legal document Part of the medical record Confidential

34. Mosby items and derived items © 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc. Not Written = Not Done All spaces (boxes) must be completely filled

35. Mosby items and derived items © 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc. Mistakes Happen Initial all cross-outs Mistake

36. Mosby items and derived items © 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc. Each state and EMS System has laws and policies that govern the practice of EMS providers Regardless of individual laws, all EMS providers face the same issues Summary

37. Mosby items and derived items © 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc. Questions?