Legal and ethical issues
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LESSON 3. LEGAL AND ETHICAL ISSUES. Introduction. Lawsuits against EMRs are rare Adhere to basic legal principles regarding emergency care State laws vary. Regulations. Federal, state and local laws and regulations govern practice of emergency medicine

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LEGAL AND ETHICAL ISSUES

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Legal and ethical issues

LESSON 3

LEGAL AND ETHICAL ISSUES


Introduction

Introduction

  • Lawsuits against EMRsare rare

  • Adhere to basic legal principles regarding emergency care

  • State laws vary


Regulations

Regulations

  • Federal, state and local laws and regulations govern practice of emergency medicine

  • Requirements vary for registering or becoming certified EMR

  • Laws state what EMRcan and can’t do


Scope of practice

Scope of Practice

  • Level of care health care professional provides with specified level of training

  • Defined by United States DOT National Emergency Medical Services Education Standards (NHTSA)

  • State laws may modify scope of practice

  • Further defined through medical oversight, including protocols, standing orders, direct oversight


Standard of care

Standard of Care

  • Howyou provide care and whatspecific care you give

  • Same care as EMR with similar training would give patient in similar circumstances

  • National standard of care based on DOT National Emergency Medical Services Education Standards

  • What you are taught in EMR training = standard of care

  • Give care as you have been taught, and you cannot be held legally liable for a negative patient outcome

  • Neglecting to follow standard of care may make you liable for negligence


Primary ethical principles in health care

Primary Ethical Principles in Health Care

  • Do no harm

  • Act in good faith

  • Act in the patient’s best interest


Ethical responsibilities

Ethical Responsibilities

  • To provide the best patient care possible

  • Make patient’s physical and emotional needs your highest priority

  • Practice care giving skills until mastered

  • Regularly attend continuing education and refresher programs

  • Review your performances after each patient care episode

  • Be honest in reporting and documentation


Consent

Consent

  • Patients have right to decide emergency care they will accept

  • Obtain person’s consent before providing care

  • Consent based on information you provide

  • A competent adult has right to refuse care


Competence

Competence

  • Determine if adult patient is competent to consent

  • Competent person can understand what is happening and implications of receiving/refusing care

  • Patient may not be competent because of intoxication, drug use or altered mental status caused by severe injury

  • Parent or legal guardian gives consent for children or mentally incompetent adults

  • If parent or guardian cannot be reached, consent is implied


Expressed consent

ExpressedConsent

  • Patient explicitly grants permission for care

  • Usually a verbal agreement or a nod

  • Must be obtained from every responsive, competent adult before giving care

  • Patient must be informed


To obtain expressed consent

To Obtain Expressed Consent

  • Identify yourself to patient

  • State your level of training

  • Explain what you think may be wrong

  • Describe care you will give and its benefits

  • Explain any risks related to care


Implied consent

Implied Consent

  • Unresponsive patient assumed to give consent

  • Consent assumed for child needing emergency care if parent or guardian is not present


Refusal of consent

Refusal of Consent

  • Competent adult patients have right to refuse medical care

  • You must honor their wishes

  • May be verbal or indicated by shaking head or pulling away

  • Person should fully understand all risks and consequences of refusing care

  • After treatment begins, patient still has right to withdraw


When a patient refuses consent

When a Patient Refuses Consent

  • When in doubt, err in favor of providing care

  • Do not argue with patient or question patient’s personal beliefs

  • Follow local protocol

  • Notify responding EMS units to evaluate situation

  • Have patient sign refusal form or have witness hear patient’s refusal


While awaiting additional ems resources if consent is refused

While Awaiting Additional EMS Resources(If Consent is Refused)

  • Try again to persuade patient to accept care

  • Determine whether patient is competent

  • Inform patient again why care is needed and what may happen if care is refused

  • Consult medical oversight as directed by local protocol

  • Consider calling for assistance from law enforcement

  • Report assessment findings and emergency medical care you have provided


Types of law

Types of Law

  • Criminal Law

  • Regulatory Law

  • State Medical Practice Acts (Statutory Law)

  • Civil Law (Tort Law)


Assault and battery

Assault and Battery

  • Assault: crime of verbally or physically threatening to touch another person without consent

  • Battery: crime of touching another person without consent

  • Caring for a competent patient who refuses care may make you guilty of assault or battery

  • Patient may file lawsuit against you


Advance directives

Advance Directives

  • Legal document

  • Identifies care person will or will not accept

  • Signed while the person is competent

  • Durable power of attorney for health care

  • Do Not Resuscitate (DNR) order

  • Generally must be signed and witnessed, and may require a physician’s signature


If you encounter an advance directive

If You Encounter an Advance Directive

  • Follow local protocol

  • DNR refers only to resuscitative care for patient whose heart has stopped  not other treatment

  • If any doubt, or if written directive is not present, give care as usual

  • Other adults and family members cannot refuse care for patient without formal advance directive

  • If family members ask you to provide care, even when DNR order is present, give care until responding EMS professionals arrive


Abandonment

Abandonment

  • Once you have begun emergency care, you have a legal obligation to continue

  • Obligation to render care ends when someone with equal or higher training takes over

  • Failing to continue care before another EMR or EMT takes over makes you guilty of abandonment, a form of negligence

  • Assessing also is considered care:

    • If you assess and release patient and patient later dies or suffers, you are guilty of abandonment

    • Leaving a patient who refuses care, without waiting for EMTs to arrive and assess patient, may also be abandonment


Abandonment failure to attempt resuscitation

Abandonment: Failure to Attempt Resuscitation

  • If you believe person is dead and do not attempt resuscitation, you may be guilty of abandonment

  • Conditions in which death can be assumed include decapitation, rigor mortis, tissue decomposition

  • If unsure what to do in any situation, call medical control for advice


Negligence

Negligence

  • Failing to give care following the accepted standard of care

  • Includes not giving care and giving improper or poor-quality care

  • If the patient suffers further injury or disability, you may be sued for negligence


Conditions for negligence

Conditions forNegligence

May be negligent if:

  • You have a duty to act

  • You breach that duty

  • The patient suffers injury or damage (including pain and suffering)

  • Your actions (or inactions) caused the injury or damage


Good samaritan laws

Good Samaritan Laws

Protect you:

  • When acting in an emergency, voluntarily and without compensation

  • When acting as a reasonable, prudent person with the same training would act

  • When performing emergency care as trained


Confidentiality

Confidentiality

  • When gathering patient’s history, you may learn private information

  • Assessment findings and emergency care provided are confidential

  • You have ethical responsibility to respect patient’s right to privacy

  • Never share patient information with others, including family members and coworkers

  • Do share information with EMS or health care personnel, and with mandatory reporting


Health insurance portability and accountability act

Health Insurance Portability and Accountability Act

  • Health Insurance Portability and Accountability Act (HIPAA) ensures confidentiality of all patient information legally protected

  • You must not disclose any patient information except to others providing treatment, law enforcement personnel or when subpoenaed by a court

  • Violations may lead to civil or criminal penalties

  • Follow the policies of your EMS system

  • When in doubt, consider everything you know about a patient to be confidential

  • A written release form signed by patient is required to share information


Special situations

Special Situations

Legal considerations are involved in other situations such as:

  • Medical identifications

  • Crime scenes

  • Reportable events

  • Documentation


Medical identification insignia

Medical Identification Insignia

  • Include necklaces, bracelets, cards worn or carried

  • Used by patients with certain medical conditions such as allergies, diabetes, epilepsy and heart conditions

  • Not looking for such insignia during patient assessment may be negligence


Crime scenes

Crime Scenes

  • Care of the patient remains the top priority

  • At potential crime scene, take precautions to preserve evidence

  • Make sure scene is safe before entering

  • Ensure law enforcement personnel are responding

  • Do not disturb any item at scene unless emergency care requires it


Crime scenes continued

Crime Scenes (continued)

  • Observe and document anything unusual at scene

  • When removing clothing to expose injury, do not cut through holes from gunshot or stabbing wounds

  • Follow directions of law enforcement personnel, and explain what is necessary to provide essential patient care


Reportable events

Reportable Events

  • EMRsare obligated to report:

    • Child, elder, and spouse abuse or domestic violence

    • Crimes, such as gunshot and knife wounds, suspicious burns, rape and sexual assault

    • Vehicle crashes

    • Certain infectious diseases

    • Exposure to a patient’s body fluids

  • Always fully document your objective findings


Documentation

Documentation

  • Documenting patient assessment and care is very important

  • Helps other EMS professionals assess and treat patient.

  • Because patient’s condition often changes, report of early assessments provides key information

  • Your record is a legal document that helps support what you saw, heard, and did at scene

  • Complete the record as soon as possible after the emergency

  • State and local EMS requirements for documentation vary

  • Many EMS systems have printed forms used by EMR


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