TRANSITION SERIES Topics for the Advanced EMT CHAPTER Legal Issues in EMS 4 4

Objectives Discuss legal terms commonly associated with EMS laws and regulations. Understand patient rights as applied to emergency and health care. Identify the Advanced EMT's role in organ donation and other special reporting situations.

Introduction Legal issues impact every patient contact. Laws are designed to protect both the patient and the care provider. If Advanced EMTs do not adhere to the legislation that they must operate within, severe legal punishment may result.

Legal Terms The Advanced EMT must be familiar with laws pertaining to EMS. In most instances, each state has a version of these laws.

An AEMT may be required to testify in court in a variety of legal settings.

Patients’ Rights Every patient that summons EMS has certain “rights.” These include: –Advance directives –Organ donation –Transport

Patients’ Rights (cont’d) Every patient that summons EMS has certain “rights.” These include: –Privacy and confidentiality –Access to emergency care –Consent –Ability to refuse care

Consent With the greater skill set and assessment skills of the Advanced EMT, additional responsibility must be taken when it comes to patient consent and obtaining true informed consent. There are greater risks with advanced treatment modalities. You must obtain the appropriate consent before beginning any care.

Special Reporting Situations EMS providers are legally bound to report certain types of emergencies. These mandatory reporting points may vary from state to state. Advanced EMTs should remain abreast of what their state requires and learn the reporting system used.

Case Study EMS is summoned to a local high school football game for an “unknown medical” emergency. Upon your arrival you are escorted by security to a remote section of the bleachers where a 17- year-old senior student is “acting strangely.” As soon as you near the patient you smell a strong odor resembling that of ETOH.

Case Study (cont’d) Scene Size-Up –Young male, 17 years of age. –A few of his friends are present; there is no indication of aggression from any of them. –Patient is of normal height and weight, and is located near a set of steps leading to the ground. –Security is on scene, and PD is en route.

Case Study (cont’d) Primary Assessment Findings –Patient is arousable with loud verbal stimuli. –Airway is intact. –Breathing is fast, but adequate. –Peripheral perfusion is intact. –No signs of trauma or struggle. –Odor resembling that of ETOH about the patient.

Case Study (cont’d) Based on the presentation thus far, what legal issues present due to his age? How is consent obtained for this patient since he is obviously incapacitated? The patient keeps mumbling “Leave me alone.” Is this a legal refusal of care?

Case Study (cont’d) Secondary Assessment –During your secondary assessment the patient becomes violent and starts swinging wildly at you and calling you names. –With the assistance of your partner and the PD, you physically restrain the patient until you have him secured to the cot with soft restraints.

Case Study (cont’d) Secondary Assessment –Transport begins to the hospital with PD following behind you.

Case Study (cont’d) What additional legal concerns have now presented? What can the Advanced EMTs do to protect themselves from litigation in this case? Does medical direction have any oversight in how the patient is being cared for?

ADVANCE DIRECTIVES

Advance Directives Document that allows a patient to define in advance what his/her wishes are should he/she become incapacitated due to medical illness or severe injury.

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

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.”

Vermont DNR/COLST Orders One essential element of providing quality end-of-life care involves honoring patient preferences. In the past a Do-Not-Resuscitate Order (DNR) has been used when a patient does not wish to have Cardiopulmonary Resuscitation (CPR). In recent years the 'old DNR' order has been incorporated into a new form known as the DNR/COLST order by the Vermont Department of Health. This more complete document is a clinician order for life- sustaining treatment (COLST) and conveys patients' wishes for CPR, intubation, transfer to the hospital, antibiotics, artificial nutrition and hydration, as well as overall treatment goals. Please note the mandated use of the Vermont Department of Health's DNR/COLST Form in the following circumstances: All out-of-hospital DNR orders are mandated to be on the Department of Health's Vermont DNR/COLST form.Vermont DNR/COLST form

What does COLST stand for? Clinician Order for Life Sustaining Treatment. In Vermont the form is referred to as DNR/COLST: Do Not Resuscitate Order/Clinician Order for Life Sustaining Treatment

What are the current statutory requirements for DNR or DNR/COLST? Must be signed by the patient’s clinician Include name of the patient, agent, guardian or other individual giving informed consent and their relationship to the patient

What is the difference between the “old DNR” order and the “DNR/COLST” order? The old “DNR” order: –Only dealt with CPR –Does not meet current legal requirements The DNR/COLST order: –Deals with CPR as well as:  Intubation  Transfer to a hospital  Antibiotics  Nutrition and Hydration  Overall goals of care –Meets all legal requirements

What are the differences between an Advance Directive and DNR/COLST? Advance Directive –Completed by patient –Allows for nuances –NOT honored in an out of hospital emergency DNR/COLST –Completed by clinician –Black and white –IS honored in an out of hospital emergency

Are “old” DNR orders still valid? DNR orders signed before July 1, 2011 are still valid They must still be signed by the patient’s clinician and include the name of the patient, guardian or other individual giving informed consent Good idea to review goals of care and treatment and get updated to DNR/COLST

DNR Orders

Clinician Signature Mandatory

Summary So long as there is EMS, there will be laws governing EMS. The Advanced EMT is solely responsible for staying abreast of laws that apply in his state.

Summary (cont’d) The best defense for preventing a lawsuit is to provide conscientious care to the patient, maintain the standard of care, follow state guidelines, and provide quality documentation on the patient care report.