Copyright © 2004, Mosby Inc. All rights reserved.

Medicolegal and Ethical Issues Slide 1 Copyright © 2004, Mosby Inc. All rights reserved. Chapter 3

Case History You respond to a nursing home to find a 90-year-old patient who has a “do not resuscitate order” (DNR). While you are transporting the patient to the hospital, he becomes unconscious and has no pulse. You respond to a nursing home to find a 90-year-old patient who has a “do not resuscitate order” (DNR). While you are transporting the patient to the hospital, he becomes unconscious and has no pulse. Slide 2 Copyright © 2004, Mosby Inc. All rights reserved.

Ethical Responsibilities Practice the golden rule when treating patients: “Do unto others as you would have them do unto you.” Slide 3 Copyright © 2004, Mosby Inc. All rights reserved.

Ethical Responsibilities Making the physical/emotional needs of the patient a priorityMaking the physical/emotional needs of the patient a priority Maintaining skills to the point of masteryMaintaining skills to the point of mastery  Continuing education  Call review  Follow-up with physician about patients treated Critically reviewing performanceCritically reviewing performance Honesty in reportingHonesty in reporting Slide 4 Copyright © 2004, Mosby Inc. All rights reserved.

Case History Your supervisor advises you that you have been subpoenaed to appear in court regarding a patient you treated 2 years ago. What would be your greatest areas of concern? Slide 5 Copyright © 2004, Mosby Inc. All rights reserved.

Key Concerns: Did I… … maintain patient confidentiality?… maintain patient confidentiality? … properly report a special situation?… properly report a special situation? … treat the patient according to the standard of care?… treat the patient according to the standard of care? … have my equipment available and in working order?… have my equipment available and in working order? … effectively document assessment and care?… effectively document assessment and care? … properly achieve consent for care?… properly achieve consent for care? … abandon care prematurely?… abandon care prematurely? Slide 6 Copyright © 2004, Mosby Inc. All rights reserved.

Confidentiality Confidential informationConfidential information Written release required to release informationWritten release required to release information Situations when no release requiredSituations when no release required  Transfer to health care providers  Reporting of incidents mandated by state law  Third-party payer billing forms  Legal subpoena Slide 7 Copyright © 2004, Mosby Inc. All rights reserved.

Special Reporting Situations Vary from state to stateVary from state to state AbuseAbuse CrimeCrime Wounds from guns and knivesWounds from guns and knives Animal bitesAnimal bites DeathDeath Infectious disease exposureInfectious disease exposure Patient restraint lawsPatient restraint laws Mentally incompetent (e.g., intoxicatedMentally incompetent (e.g., intoxicated with injuries) with injuries) Slide 8 Copyright © 2004, Mosby Inc. All rights reserved.

Scope of Practice Legal duties to the patient, medical director, and publicLegal duties to the patient, medical director, and public Defined by state legislationDefined by state legislation Enhanced by medical directionEnhanced by medical direction  Protocols and standing orders National Standard CurriculumNational Standard Curriculum Legal right to function as an EMT-BasicLegal right to function as an EMT-Basic  May be contingent on medical direction Slide 9 Copyright © 2004, Mosby Inc. All rights reserved.

Standard of Care Knowledge, laws, standards, policies, and guidelines that provide the basis of practiceKnowledge, laws, standards, policies, and guidelines that provide the basis of practice  Examples »DOT National Standard Curriculum for the EMT-Basic »American Heart Association CPR guidelines »Protocols »State regulations State laws may also define testing standards.State laws may also define testing standards. Expert witnesses may help define standard of care via deposition or testimony.Expert witnesses may help define standard of care via deposition or testimony. Slide 10 Copyright © 2004, Mosby Inc. All rights reserved.

Equipment Legally, the EMT-Basic is expected toLegally, the EMT-Basic is expected to  provide reasonable care  carry the appropriate equipment in working order Equipment failure may provide a basis for a lawsuitEquipment failure may provide a basis for a lawsuit Equipment failure should be carefully documented in the patient recordEquipment failure should be carefully documented in the patient record Slide 11 Copyright © 2004, Mosby Inc. All rights reserved.

Negligence Deviation from the accepted standard of care resulting in injury to the patientDeviation from the accepted standard of care resulting in injury to the patient Ingredients of medical malpracticeIngredients of medical malpractice  Duty to act  Breach of duty  Injury/damages  Causal connection to EMT Slide 12 Copyright © 2004, Mosby Inc. All rights reserved.

Duty to Act ImpliedImplied  Patient calls and dispatcher confirms response  Patient treatment is initiated. FormalFormal  EMS agency has a written contract with a municipality Legal duty to act may not exist.Legal duty to act may not exist.  Moral/ethical considerations may exist Slide 13 Copyright © 2004, Mosby Inc. All rights reserved.

Immunities Good Samaritan LawsGood Samaritan Laws  Designed to protect volunteers »Medical »Lay rescuers Protection of government workers (e.g., military)Protection of government workers (e.g., military) Slide 14 Copyright © 2004, Mosby Inc. All rights reserved.

Consent ExpressedExpressed ImpliedImplied ChildrenChildren Mentally incompetent patientsMentally incompetent patients Slide 15 Copyright © 2004, Mosby Inc. All rights reserved.

Assault/Battery Unlawfully touching a person without consentUnlawfully touching a person without consent Providing care without consentProviding care without consent Slide 16 Copyright © 2004, Mosby Inc. All rights reserved.

Refusals Patient has the right to refuse treatmentPatient has the right to refuse treatment Patient may withdraw from treatment at any timePatient may withdraw from treatment at any time Refusals must be made by mentally competent adultsRefusals must be made by mentally competent adults Patient must be informed of risks and consequences of refusalPatient must be informed of risks and consequences of refusal When in doubtWhen in doubt  Contact medical direction.  Err in favor of providing care. Slide 17 Copyright © 2004, Mosby Inc. All rights reserved.

Documentation of Refusal – Process Try to persuade the patient to allow treatment.Try to persuade the patient to allow treatment. Ensure that the patient is competent to make decision.Ensure that the patient is competent to make decision. Inform the patient of risks and consequences.Inform the patient of risks and consequences. Consult medical direction (per local protocol).Consult medical direction (per local protocol). Consider assistance from law enforcement.Consider assistance from law enforcement. Document any findings and care given.Document any findings and care given. Patient should sign a refusal form.Patient should sign a refusal form. Never make an independent decision not to transport.Never make an independent decision not to transport. Slide 18 Copyright © 2004, Mosby Inc. All rights reserved.

AbandonmentDefinition: Termination of patient care without ensuring the continuation of care at the same level or higher Termination of patient care without ensuring the continuation of care at the same level or higher Slide 19 Copyright © 2004, Mosby Inc. All rights reserved.

Intoxicated, Irrational, and Emotionally Disturbed Patients Emotionally disturbed patients represent an area of high legal risk.Emotionally disturbed patients represent an area of high legal risk. Always exercise caution.Always exercise caution. When forcible removal is necessary:When forcible removal is necessary:  Care should be taken to not harm the patient  Soft restraints should be used  Precise documentation is essential Slide 20 Copyright © 2004, Mosby Inc. All rights reserved.

Advanced Directives DNR Orders Patient has the right to refuse resuscitative effortsPatient has the right to refuse resuscitative efforts Generally, a written physician order is required.Generally, a written physician order is required. Follow state and local legislation/protocols.Follow state and local legislation/protocols. When in doubt, begin resuscitation efforts.When in doubt, begin resuscitation efforts. Slide 21 Copyright © 2004, Mosby Inc. All rights reserved.

Donor and Organ Harvesting Individual may decide in advance to donate organs.Individual may decide in advance to donate organs.  May be indicated on a driver’s license or donor card Treat the same as any other patient.Treat the same as any other patient. If you become aware of a patient’s organ donor status, you should communicate this to the hospital or medical direction.If you become aware of a patient’s organ donor status, you should communicate this to the hospital or medical direction. Slide 22 Copyright © 2004, Mosby Inc. All rights reserved.

Crime Scene/Evidence Preservation Dispatch should notify police.Dispatch should notify police. Responsibility of EMT:Responsibility of EMT:  Emergency care is priority  Do not disturb scene unless emergency care requires it  Observe and document anything unusual at the scene If possible, do not cut clothing from patientIf possible, do not cut clothing from patient Slide 23 Copyright © 2004, Mosby Inc. All rights reserved.

Risk Management Act according to the standard of care.Act according to the standard of care. Act in the best interest of the patient.Act in the best interest of the patient. Document your actions.Document your actions. Slide 24 Copyright © 2004, Mosby Inc. All rights reserved.