1. Slide 1 Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Medicolegal and Ethical Issues Chapter 3

2. Slide 2 Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. 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.

3. Slide 3 Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Ethical Responsibilities Practice the golden rule when treating patients: “Do unto others as you would have them do unto you.”

4. Slide 4 Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Ethical Responsibilities  Making the physical/emotional needs of the patient a priority  Maintaining skills to the point of mastery  Continuing education  Call review  Follow-up with physician about patients treated  Critically reviewing performance  Honesty in reporting

5. Slide 5 Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier 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?

6. Slide 6 Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Key Concerns: Did I…  … maintain patient confidentiality?  … properly report a special situation?  … treat the patient according to the standard of care?  … have my equipment available and in working order?  … effectively document assessment and care?  … properly achieve consent for care?  … abandon care prematurely?

7. Slide 7 Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Confidentiality  Confidential information  Written release required to release information  Situations when no release required  Transfer to health care providers  Reporting of incidents mandated by state law  Third-party payer billing forms  Legal subpoena

8. Slide 8 Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Special Reporting Situations  Vary from state to state  Abuse  Crime  Wounds from guns and knives  Animal bites  Death  Infectious disease exposure  Patient restraint laws  Mentally incompetent (e.g., intoxicated with injuries) with injuries)

9. Slide 9 Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Scope of Practice  Legal duties to the patient, medical director, and public  Defined by state legislation  Enhanced by medical direction  Protocols and standing orders  National Standard Curriculum  Legal right to function as an EMT-Basic  May be contingent on medical direction

10. Slide 10 Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Standard of Care  Knowledge, laws, standards, policies, and guidelines that provide the basis of practice  Examples DOT National Standard Curriculum for the EMT-Basic DOT National Standard Curriculum for the EMT-Basic American Heart Association CPR guidelines American Heart Association CPR guidelines Protocols Protocols State regulations State regulations  State laws may also define testing standards.  Expert witnesses may help define standard of care via deposition or testimony.

11. Slide 11 Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Equipment  Legally, the EMT-Basic is expected to  provide reasonable care  carry the appropriate equipment in working order  Equipment failure may provide a basis for a lawsuit  Equipment failure should be carefully documented in the patient record

12. Slide 12 Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Negligence  Deviation from the accepted standard of care resulting in injury to the patient  Ingredients of medical malpractice  Duty to act  Breach of duty  Injury/damages  Causal connection to EMT

13. Slide 13 Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Duty to Act  Implied  Patient calls and dispatcher confirms response  Patient treatment is initiated.  Formal  EMS agency has a written contract with a municipality  Legal duty to act may not exist.  Moral/ethical considerations may exist

14. Slide 14 Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Immunities  Good Samaritan Laws  Designed to protect volunteers Medical Medical Lay rescuers Lay rescuers  Protection of government workers (e.g., military)

15. Slide 15 Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Consent  Expressed  Implied  Children  Mentally incompetent patients

16. Slide 16 Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Assault/Battery  Unlawfully touching a person without consent  Providing care without consent

17. Slide 17 Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved.Refusals  Patient has the right to refuse treatment  Patient may withdraw from treatment at any time  Refusals must be made by mentally competent adults  Patient must be informed of risks and consequences of refusal  When in doubt  Contact medical direction.  Err in favor of providing care.

18. Slide 18 Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Documentation of Refusal – Process  Try to persuade the patient to allow treatment.  Ensure that the patient is competent to make decision.  Inform the patient of risks and consequences.  Consult medical direction (per local protocol).  Consider assistance from law enforcement.  Document any findings and care given.  Patient should sign a refusal form.  Never make an independent decision not to transport.

19. Slide 19 Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier 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

20. Slide 20 Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Intoxicated, Irrational, and Emotionally Disturbed Patients  Emotionally disturbed patients represent an area of high legal risk.  Always exercise caution.  When forcible removal is necessary:  Care should be taken to not harm the patient  Soft restraints should be used  Precise documentation is essential

21. Slide 21 Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Advanced Directives DNR Orders  Patient has the right to refuse resuscitative efforts  Generally, a written physician order is required.  Follow state and local legislation/protocols.  When in doubt, begin resuscitation efforts.

22. Slide 22 Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Donor and Organ Harvesting  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.  If you become aware of a patient’s organ donor status, you should communicate this to the hospital or medical direction.

23. Slide 23 Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Crime Scene/Evidence Preservation  Dispatch should notify police.  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 patient

24. Slide 24 Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Risk Management  Act according to the standard of care.  Act in the best interest of the patient.  Document your actions.