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Prepartory EMS Safety: Legal and Ethical Issues

Level 4

Legal and Ethical Issues in EMS

Overview | Assessment | Treatment | Roles

Objectives

In this Ethics and Legal Issues course you will earn 2 CE hours. This course is accredited for all levels since all EMS personnel are technically First Responders.

At the end of this course you will be able to:

  • Define the First Responder scope of care.
  • Differentiate between expressed and implied consent.
  • Discuss the implications for the First Responder in patient refusal of transport.
  • Clarify issues of abandonment, negligence, and battery and their implications to the First Responder.
  • Explain the importance, necessity and legality of patient confidentiality.
  • List the actions that a First Responder should take to assist in the preservation of a crime scene.
  • Clarify advance directives and DNR procedures.[/1]]

References for content used by permission are on the left side under "EMS Resources." A technical :word: when clicked instantly accesses the EMS glossary online.

There are four sections: Overview, Assessment, Treatment, and Roles. Take the section tests in order by clicking the Take Test button. Your results are saved if you are interrupted. Then do the next section—no lost time or effort with mini-test sections!

EMS Course Levels

Overview

Grandpa is having chest pains. The family calls 911. First Responders come to the house, but Grandpa refuses treatment. What do you do?

Legal and ethical issues are a vital element of the First Responder's daily life. Should a First Responder stop and treat an automobile crash victim when off duty? Should patient information be released to the attorney on the telephone? Can a child with a broken arm be treated even though the parents are not at home and/or only the child care provider is around?

These and many other legal and ethical questions face the First Responder every day. Guidance will be given in this lesson to answer these questions and learn how to make the correct decision when other legal and ethical questions arise.

heart assessment

Definitions

  • Abandonment - terminating care of the patient without insuring that care will continue at the same level or higher.
  • Assault & Battery - unlawfully touching a patient without consent and providing emergency medical care when a competent patient does not consent to the emergency medical care. (However, no universal definition of assault and battery exists for EMS personnel.)
  • Confidentiality - acting professionally to protect the privacy of those in your care.
  • Competence - the ability to understand the questions of the First Responder and to understand the implications of decisions made.
  • Implied Consent - Consent from the unresponsive patient requiring emergency intervention is based on the assumption that the unresponsive patient would consent to life saving interventions.
  • Negligence - deviation from the accepted standard of care resulting in further injury to patients.[/1]]
Emergency Stop
Assessment

Scope of Care

Legal duties to the patient, medical director, and public provide for the well-being of the patient by rendering necessary interventions outlined in the scope of care. They are defined by state law and enhanced by medical oversight through the use of protocols and standing orders. These standards are referenced to the National Standard Curricula.

The legal right to function as a First Responder may be contingent upon medical oversight.

  • Telephone/radio communications.
  • Approved standing orders/protocols.
  • Responsibility to medical oversight.

Ethical Responsibilities

  1. Make the physical/emotional needs of the patient a priority.
  2. Practice of skills to the point of mastery.
  3. Attend continuing education/refresher programs.
  4. Review performances, seeking ways to improve response time, patient outcome, and communication.
  5. Be honest in reporting.

Competence

Competence is the ability to understand the questions of the First Responder and to understand the implications of decisions made. In order for a First Responder to receive consent or refusal of care, the First Responder should determine competence. This may not be possible in certain cases:

  • Intoxication
  • Drug ingestion
  • Serious injury
  • Mental incompetence[/1]]

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Treatment

Consent

A competent patient has the right to make decisions regarding care and must consent to emergency medical care. The acceptance of care is based on the information provided. There are two types of consent for competent patients: expressed and implied.

Expressed

Patients must be competent and of legal age and be informed of the steps of the procedures and all related risks. Procedures for obtaining consent from each responsive, mentally competent adult before rendering emergency medical care are listed below:

  • Identify yourself.
  • Inform the patient of your level of training.
  • Explain the procedures to the patient.
  • Identify the benefits.
  • Identify the risks.

Implied

Consent from the unresponsive patient requiring emergency intervention is based on the assumption that the unresponsive patient would consent to life saving interventions.

Children and Mentally Incompetent Adults

Consent for emergency medical care must be obtained from the parent or legal guardian. Emancipation issues and state regulations regarding age of minors are factors to consider. When life threatening situations exist and the parent or legal guardian is not available for consent, emergency medical care should be rendered based on implied consent.[/1]]

forms

Roles and Responsibilities

Advance Directives and Do Not Resuscitate (DNR) Orders

Patients have the right to refuse resuscitative efforts. In general, refusal requires written orders from a physician. Review your own state and local legislation/protocols relative to DNR orders and advance directives. When in doubt or when written orders are not present, the First Responder should begin resuscitation efforts.

Refusals

Competent adult patients have the right to refuse emergency medical care. The First Responder should not make an independent decision regarding the refusal of care.The patient may withdraw from emergency medical care at any time. For example, an unresponsive patient regains responsiveness and refuses transport to the hospital. Refusals must be made by mentally competent adults following the rules of expressed consent.

The patient must be informed of and fully understand all the risks and consequences associated with refusal of emergency medical care. When in doubt, err in favor of providing care. The First Responder must ensure that additional EMS resources will evaluate the patient.

While awaiting arrival of additional EMS resources the First Responder should:

  1. Try again to persuade patients to accept care.
  2. Determine whether patients are able to make rational, informed decisions; in other words, they are not under the influence of alcohol or other drugs or the effects of the injury or illness.
  3. Inform them why they should accept care and what may happen to them if they do not.
  4. Consult medical oversight as directed by local protocol.
  5. Consider assistance of law enforcement.
  6. Report any assessment findings and emergency medical care provided.

Assault & Battery - unlawfully touching a patient without consent and providing emergency medical care when a competent patient does not consent to the emergency medical care. (However, no universal definition of assault and battery exists for EMS personnel.)

Abandonment - terminating care of the patient without insuring that care will continue at the same level or higher.

Negligence - deviation from the accepted standard of care resulting in further injury to patients.

  • Duty to Act
    • A contractual or legal obligation must exist.
    • Formal - As part of First Responder's occupation, they are required to render emergency medical care.
    • Implied
      • Patient calls for assistance and the dispatcher confirms that help is being sent.
      • The First Responders are dispatched as part of the EMS response.
      • Emergency medical care is initiated for patients.
    • "Legal" duty to act varies according to state law where there are moral and ethical considerations.
    • Specific state regulations regarding duty to act will guide your decisions.
    • Duty to act appropriately means following guidelines for standards of care and acting as another prudent individual would in that situation.
  • Breach of the duty means failure to act or failure to act appropriately.
  • Actions or lack of actions of the First Responder caused the physical or psychological injury/damage.

Confidentiality

Confidential information includes:

  • Patient history gained through interview.
  • Assessment findings.
  • Emergency medical care rendered.

Releasing confidential information:

  • Requires a written release form signed by the patient. Do not release any patient information on request, unless authorized in writing.
  • Does not require a release form when:
    • Other health care providers need to know information to continue care.
    • State law requires reporting incidents (examples: rape, abuse or gun shot wounds).
    • Subpoena is issued.

Special Situations:

Medical Identification Insignia bracelet, necklace, or card indicates a medical condition of the patient, such as allergies, diabetes, epilepsy.

Potential Crime Scene/Evidence Preservation

  • Dispatch should notify police personnel.
  • Emergency medical care of the patient is the First Responder's priority.
  • Do not disturb any item at the scene unless emergency medical care requires it.
  • Observe and document anything unusual at the scene.
  • If possible, do not cut through holes in clothing from gunshot wounds or stabbing.

Documentation

  • Fundamental medical documentation:
    • System/local requirements for documentation.
    • State requirements for documentation.
  • Special reporting situations are established by state regulations or statutes and may vary from state to state.
  • Commonly required reporting situations
    • Abuse
      • Child
      • Elderly
      • Spouse
    • Crime
      • Wounds sustained or potentially sustained by violent crime
      • Sexual assault
    • Infectious disease exposure

Summary

Legal and ethical issues are present in every aspect of patient care. Decisions to treat or not treat a patient, to release or not release information, to report or not report an incident all require a knowledge of current state and local legislation, policy, and protocol. Up-to-date knowledge of the current legal interpretation of issues such as negligence, battery, confidentiality, consent, and refusal of emergency medical care is essential for the First Responder.[/1]]

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