Bledsoe v1 ch07_lecture

Copyright © 2017, 2013, 2009 Pearson
Education, Inc. All Rights Reserved.
Bryan E. Bledsoe
Richard A. Cherry
Robert S. Porter
Paramedic Care: Principles & Practice
Volume 1, 5e
Chapter 7
Medical–Legal Aspects
of Out-of-Hospital
Care

Bryan E. Bledsoe
Richard A. Cherry
Robert S. Porter
Standard
• Preparatory (Medical–Legal and Ethics)

Bryan E. Bledsoe
Richard A. Cherry
Robert S. Porter
Competency
• Integrates comprehensive knowledge of EMS
systems, the safety and well-being of the
paramedic, and medical–legal and ethical issues,
which is intended to improve the health of EMS
personnel, patients, and the community.

Bryan E. Bledsoe
Richard A. Cherry
Robert S. Porter
Introduction
• Paramedics must:
– Be familiar with legal issues they encounter in field
– Be prepared to make medical decisions and
appropriate legal decisions
• Laws vary state to state; protocols vary county to
county.
• Specific legal question: rely on advice of attorney.

Bryan E. Bledsoe
Richard A. Cherry
Robert S. Porter
Legal Duties and Ethical Responsibilities
• As paramedic, you have legal duties to patient,
crew, medical director, public.
• Based on accepted standards; set by statutes and
regulations
• Best protection from liability:
– Perform systematic patient assessment.
– Provide appropriate medical care.
– Accurate and complete documentation.

Bryan E. Bledsoe
Richard A. Cherry
Robert S. Porter
Figure 7-1 Each EMS response has the potential of involving paramedics in the legal system.

Bryan E. Bledsoe
Richard A. Cherry
Robert S. Porter
• Ethical Responsibilities
– Respond promptly to both physical and emotional
needs of every patient.
– Treat all patients and their families with courtesy and
respect.
– Maintain skills and medical knowledge.
– Participate in continuing education programs,
seminars, refresher training.

Bryan E. Bledsoe
Richard A. Cherry
Robert S. Porter
• Ethical Responsibilities
– Critically review your performance; constantly seek
improvement.
– Report honestly and with respect for patient
confidentiality.
– Work cooperatively with and respect other emergency
professionals.

Bryan E. Bledsoe
Richard A. Cherry
Robert S. Porter
• Ethical standards are not laws.
– Principles that identify desirable conduct by members
of particular group
• Morality: principle of right and wrong as governed
by individual conscience.

Bryan E. Bledsoe
Richard A. Cherry
Robert S. Porter
• The Legal System
– Constitutional law: based on Constitution of United
States; protects people against governmental abuse.
– Common law ("case" or "judge-made"): society's
acceptance of customs and norms over time; changes
and grows over years.

Bryan E. Bledsoe
Richard A. Cherry
Robert S. Porter
– Statutory law (legislative): does not come from court
decisions; created by lawmaking or legislative bodies.
– Regulatory law (administrative): enacted by
administrative or governmental agency at either federal
or state level.

Bryan E. Bledsoe
Richard A. Cherry
Robert S. Porter
– Criminal law: crime and punishment.
– Civil law: noncriminal issues (personal injury, contract
disputes, matrimonial issues).
 Plaintiff: person initiating litigation.
 Defendant: person against whom complaint is made.

Bryan E. Bledsoe
Richard A. Cherry
Robert S. Porter
– Tort law: civil wrongs committed by one individual
against another.
– Trial courts: judge or jury determines outcome of
individual cases.
– Appellate courts: hear appeals of decisions by trial or
appeals courts.

Bryan E. Bledsoe
Richard A. Cherry
Robert S. Porter
• Anatomy of a Civil Lawsuit
– Incident
– Investigation
– Filing of complaint
– Answering of complaint
– Discovery
 Examination before trial (deposition)
 Interrogatory
 Requests for document production

Bryan E. Bledsoe
Richard A. Cherry
Robert S. Porter
• Anatomy of a Civil Lawsuit
– Trial
– Decision
– Appeal
– Settlement

Bryan E. Bledsoe
Richard A. Cherry
Robert S. Porter
• Laws Affecting EMS and the Paramedic
– Scope of Practice
 Range of duties and skills paramedics allowed and expected to
perform
 Set by state law or regulation and/or by local medical direction
 Policy to guide paramedics in dealing with intervener
physicians

Bryan E. Bledsoe
Richard A. Cherry
Robert S. Porter
– Certification: recognition granted to individual who has
met qualifications to participate in certain activity.
– Licensure: used to regulate occupations.
– Understand EMS laws and regulations in your state.

Bryan E. Bledsoe
Richard A. Cherry
Robert S. Porter
– Special motor vehicle laws govern operation of
emergency vehicles and equipment; vary state to state.
– Each state has different laws to protect public.
 Report spousal abuse, child abuse and neglect, abuse of
elderly, sexual assault, gunshot and stab wounds, animal bite,
communicable diseases.

Bryan E. Bledsoe
Richard A. Cherry
Robert S. Porter
– Laws to protect paramedics:
 Immunity: exemption from legal liability.
 Good Samaritan laws: immunity for people who assist at
medical emergency.
 Ryan White Comprehensive AIDS Resources Emergency Act
(Ryan White CARE Act): exposure to bloodborne or airborne
pathogens.

Bryan E. Bledsoe
Richard A. Cherry
Robert S. Porter
Legal Accountability of the Paramedic
• Required to provide level of care to patients
consistent with education and training; equal to
other paramedics with equivalent training.
• Expected to perform duties in reasonable and
prudent manner.
– Intentional tort: civil wrong committed by one person
against another based on willful act.

Bryan E. Bledsoe
Richard A. Cherry
Robert S. Porter
• Negligence and Medical Liability
– Negligence: deviation from accepted standards of care
recognized by law for protection of others against
unreasonable risk of harm.

Bryan E. Bledsoe
Richard A. Cherry
Robert S. Porter
Table 7-1 EMS Liability Claims
Summary of 275 EMS Liability Claims from a Large National EMS Insurer for a Two-Year Period
Cause Percentage
Patient handling 45%
Emergency vehicle movement or collision 31%
Medical management 11%
EMS response or transport 8%
Lack or failure of equipment 4%
Other Causes 9%

Bryan E. Bledsoe
Richard A. Cherry
Robert S. Porter
– Duty to act: formal contractual or informal legal
obligation to provide care.
 Duty to respond to scene and render care to ill or injured
patients
 Duty to obey federal, state, local laws and regulations
 Duty to operate emergency vehicle reasonably and prudently

Bryan E. Bledsoe
Richard A. Cherry
Robert S. Porter
 Duty to provide care and transportation to expected standard
of care
 Duty to provide care and transportation consistent with scope
of practice and local medical protocols

Bryan E. Bledsoe
Richard A. Cherry
Robert S. Porter
 Duty to continue care and transportation through to appropriate
conclusions

Bryan E. Bledsoe
Richard A. Cherry
Robert S. Porter
– Breach of duty:
 Malfeasance: performance of wrongful or unlawful act by
paramedic.
 Misfeasance: performance of legal act in manner harmful or
injurious.
 Nonfeasance: failure to perform required act or duty.

Bryan E. Bledsoe
Richard A. Cherry
Robert S. Porter
– Res ipsa loquitur:
 Complainant must prove damages would not have occurred in
absence of somebody's negligence.
 Instruments causing damages were under defendant's control
at all times.
 Patient did nothing to contribute to his own injury.

Bryan E. Bledsoe
Richard A. Cherry
Robert S. Porter
– Negligence per se (automatic): paramedic violates
statute and injury to plaintiff results.
– Actual damages: plaintiff must prove he was actually
harmed in way that can be compensated by award of
damages.
 Plaintiff may seek punitive (punishing) damages.

Bryan E. Bledsoe
Richard A. Cherry
Robert S. Porter
– Proximate cause: action or inaction of paramedic
immediately caused or worsened damage suffered by
plaintiff.
 Plaintiff needs to prove damage to patient was reasonably
foreseeable.

Bryan E. Bledsoe
Richard A. Cherry
Robert S. Porter
– Defenses to negligence:
 Good Samaritan laws
 Governmental immunity
 Statute of limitations
 Contributory or comparative negligence

Bryan E. Bledsoe
Richard A. Cherry
Robert S. Porter
– Appropriate education, training, continuing education
– Appropriate medical direction
– Accurate, thorough documentation
– Professional attitude and demeanor
– Act in good faith
– Use common sense
– Covered by medical liability insurance

Bryan E. Bledsoe
Richard A. Cherry
Robert S. Porter
• Special Liability Concerns
– Paramedic's medical director: may be liable to patient
for negligent supervision of paramedic.
– Borrowed servant doctrine: if supervising other
emergency care providers, you may be liable for any
negligent act they commit.

Bryan E. Bledsoe
Richard A. Cherry
Robert S. Porter
– Civil rights: patient may sue for violating his civil rights
if you fail to render care for discriminatory reason.
– Off-duty paramedic: liability may arise in situation in
which off-duty paramedic renders assistance at scene.

Bryan E. Bledsoe
Richard A. Cherry
Robert S. Porter
– Airway issues: failure to secure airway or failure to
recognize airway improperly placed can result in
devastating or fatal injuries for patient.
– Restraint issues: patient who must be physically or
chemically restrained due to patient's behavior.

Bryan E. Bledsoe
Richard A. Cherry
Robert S. Porter
– Restraint issues:
 Excited delirium syndrome (ExDS)
 Restraint or positional asphyxia.
– Understand and practice safe restraint techniques.
– Medical restraint is high-risk issue.

Bryan E. Bledsoe
Richard A. Cherry
Robert S. Porter
Paramedic-Patient Relationships
• Confidentiality
– Medical or personal information (medical history,
assessment findings, treatment) will not be released to
third party without express permission of patient or
legal guardian.

Bryan E. Bledsoe
Richard A. Cherry
Robert S. Porter
• Confidentiality
– Patient consents to release of his records.
– Other medical care providers have need to know.
– EMS is required by law to release a patient's medical
records.
– Third-party billing requirements

Bryan E. Bledsoe
Richard A. Cherry
Robert S. Porter
• Health Insurance Portability and Accountability Act
(HIPAA)
– Changed methods EMS providers use to file for
insurance and Medicare payments.
– Added layers of privacy protection for patients.
– All EMS employees trained in HIPAA compliance.
– Patients rights regarding health records.

Bryan E. Bledsoe
Richard A. Cherry
Robert S. Porter
• Defamation
– Person makes intentional false communication that
injures another person's reputation or good name.

Bryan E. Bledsoe
Richard A. Cherry
Robert S. Porter
• Libel
– Act of injuring person's character, name, or reputation
by false statements in writing or mass media with
malicious intent or reckless disregard for falsity of
statements.

Bryan E. Bledsoe
Richard A. Cherry
Robert S. Porter
• Slander
– Act of injuring person's character, name, or reputation
by false or malicious statements spoken with malicious
intent or reckless disregard for falsity of statements.

Bryan E. Bledsoe
Richard A. Cherry
Robert S. Porter
• Invasion of Privacy
– Release of confidential information, without legal
justification, regarding patient's private life; exposes
patient to ridicule, notoriety, embarrassment.

Bryan E. Bledsoe
Richard A. Cherry
Robert S. Porter
• Consent
– Consent: granting of permission to treat.
– By law, you must get patient's consent before you can
provide medical care or transport.
– Patient must be competent to give or withhold consent.

Bryan E. Bledsoe
Richard A. Cherry
Robert S. Porter
• Consent
– Informed consent: based on full disclosure of
information.
 Nature of illness or injury; recommended treatments
 Risks, dangers, benefits of treatments
 Alternative treatment possibilities; risks, dangers, benefits of
accepting each one
 Dangers of refusing treatment and/or transport

Bryan E. Bledsoe
Richard A. Cherry
Robert S. Porter
• Consent
– Expressed consent: most common; person directly
grants permission to treat—verbally, nonverbally, in
writing.
– Implied consent: patient requires emergency
intervention but is mentally, physically, or emotionally
unable to grant consent.

Bryan E. Bledsoe
Richard A. Cherry
Robert S. Porter
• Consent
– Involuntary consent: court orders patients to undergo
treatment, even though they may not want it.
– Competent adult in police custody does not lose the
right to make medical decisions for himself.

Bryan E. Bledsoe
Richard A. Cherry
Robert S. Porter
• Consent
– Minor: consent obtained from parent, legal guardian,
court-appointed custodian.
– Emancipated minor: considered adult.
– Competent adult may withdraw consent for any
treatment at any time; refusal must be informed.

Bryan E. Bledsoe
Richard A. Cherry
Robert S. Porter
Figure 7-3 Example of a "release-from-liability" form.

Bryan E. Bledsoe
Richard A. Cherry
Robert S. Porter
• Refusal of Service
– Be sure patient legally permitted to refuse care; must
be competent adult.
– Make multiple and sincere attempts to convince patient
to accept care.
– Enlist help of others (family or friends) to convince
patient to accept care.

Bryan E. Bledsoe
Richard A. Cherry
Robert S. Porter
– Make certain patient fully informed about implications
of decision and potential risks of refusing care.
– Consult with on-line medical direction.
– Have patient and disinterested witness sign release-
from-liability form.

Bryan E. Bledsoe
Richard A. Cherry
Robert S. Porter
– Advise patient he may call you again for help, if
necessary.
– Attempt to get patient's family or friends to stay with
patient.
– Document entire situation thoroughly on patient care
report.

Bryan E. Bledsoe
Richard A. Cherry
Robert S. Porter
• Problem Patients
– Violent
– Victim of drug overdose
– Intoxicated adult or minor
– Ill or injured minor with no adult available to provide
consent for medical treatment

Bryan E. Bledsoe
Richard A. Cherry
Robert S. Porter
• Problem Patients
– Attempt to develop trust and rapport.
– Refusal form should be completed and witnessed by
police officer.
– If situation dangerous, police officers or family should
consider legal measures.
– Conversation with patient and refusal witnessed by
disinterested third party.

Bryan E. Bledsoe
Richard A. Cherry
Robert S. Porter
• Boundaries Issues
– Professional boundaries: ethical and societal limits to
interactions between paramedics or health care
personnel and patients they serve.
 Crossing professional boundaries can result in breaching
responsibilities.

Bryan E. Bledsoe
Richard A. Cherry
Robert S. Porter
• Boundaries Issues
– Danger zones:
 Being tired: fatigue can lead to problems (medication errors,
poor decision making, vehicle crashes).
 Being seduced: led away from one's principles, ethics, faith,
allegiance.
 Being unprepared

Bryan E. Bledsoe
Richard A. Cherry
Robert S. Porter
• Legal Complications Related to Consent
– Abandonment: termination of paramedic-patient
relationship without providing for continuation of care
while still needed and desired by patient.

Bryan E. Bledsoe
Richard A. Cherry
Robert S. Porter
– Assault: unlawfully placing person in apprehension of
immediate bodily harm without his consent.
– Battery: unlawful touching of another individual without
his consent.

Bryan E. Bledsoe
Richard A. Cherry
Robert S. Porter
– False imprisonment: intentional and unjustifiable
detention of person without his consent or other legal
authority; may result in civil or criminal liability.

Bryan E. Bledsoe
Richard A. Cherry
Robert S. Porter
• Reasonable Force
– Minimum amount of force necessary to ensure patient
does not cause injury to himself, you, or others.
 Use of excessive force can result in liability for paramedic.
 Force used as punishment considered assault and battery.

Bryan E. Bledsoe
Richard A. Cherry
Robert S. Porter
• Reasonable Force
– Use of restraints may be indicated for combative
patient.
– Restraints conform to local protocols.
– Restraining devices: straps, jackets, restraining
blankets.
– Use least amount of force to safely control patient while
causing him least amount of discomfort.

Bryan E. Bledsoe
Richard A. Cherry
Robert S. Porter
Figure 7-5 Patient restraint is a high-risk endeavor. The safety of personnel and the patient
should be the highest priority.

Bryan E. Bledsoe
Richard A. Cherry
Robert S. Porter
• Patient Transportation
– Maintain same level of care as was initiated at scene.
– Emergency vehicle operations: be familiar with state
and local laws.
– Patient choice of destination and insurance company
protocols
– Facility selection based on patient request, patient
need, facility capability

Bryan E. Bledsoe
Richard A. Cherry
Robert S. Porter
Resuscitation Issues
• You are under obligation to begin resuscitative
efforts when patient unresponsive, pulseless,
apneic.
• Resuscitation not indicated:
– Do Not Resuscitate (DNR) order
– Obviously dead; obvious tissue decomposition;
extreme lividity
– Scene too hazardous to enter.

Bryan E. Bledsoe
Richard A. Cherry
Robert S. Porter
• Advance Directives
– Document to ensure certain treatment choices honored
when patient is unconscious or otherwise unable to
express choice of treatments.
 Living wills, durable powers of attorney for health care, Do Not
Resuscitate orders, organ donor cards

Bryan E. Bledsoe
Richard A. Cherry
Robert S. Porter
– Living will: legal document that allows person to specify
the kinds of medical treatment he wishes to receive
should need arise.

Bryan E. Bledsoe
Richard A. Cherry
Robert S. Porter
– Do Not Resuscitate (DNR) order: legal document that
indicates to medical personnel which, if any, life-
sustaining measures should be taken when patient's
heart and respiratory functions have ceased.
 Valid DNR orders should be honored as your protocols allow.

Bryan E. Bledsoe
Richard A. Cherry
Robert S. Porter
– Physician Orders for Life-Sustaining Treatment
(POLST)
 Designed for terminally ill patients.
 Terminally ill patient and physician consult on patient's wishes
and incorporate wishes into specific orders.
 Not all states have adopted POLST.

Bryan E. Bledsoe
Richard A. Cherry
Robert S. Porter
– Potential Organ Donation
 Organs and tissues in very high demand and short supply
 EMS systems vital link in organ procurement and transplant
process
 Consult on-line medical direction when you have identified
potential donor.

Bryan E. Bledsoe
Richard A. Cherry
Robert S. Porter
• Death in the Field
– Must be appropriately dealt with and thoroughly
documented.
– Follow state and local protocols.
– Contact on-line medical direction for guidance.

Bryan E. Bledsoe
Richard A. Cherry
Robert S. Porter
Crime and Accident Scenes
• If you believe a crime committed on scene,
immediately contact law enforcement if not
already involved.
• Protect yourself and safety of other EMS
personnel; primary consideration.
• Once crime scene deemed safe, initiate patient
contact and medical care.

Bryan E. Bledsoe
Richard A. Cherry
Robert S. Porter
• Do not move or touch anything at crime scene
unless necessary for patient care.
• Do your best to protect potential evidence.
• If you need to remove items from scene, be sure
to document your actions and notify investigating
officers.

Bryan E. Bledsoe
Richard A. Cherry
Robert S. Porter
• Treat scene of accident in same way.
• Ensure your own safety and safety of crew.
• Treat patients as medically indicated.
• Use resources available to you.
• Be prepared to summon additional personnel and
equipment.

Bryan E. Bledsoe
Richard A. Cherry
Robert S. Porter
Duty to Report
• When abuse or neglect suspected, you must
balance need to protect patient confidentiality
against need to notify proper authorities.
• Act with patient's best interest in mind.
• Many states have rules that require EMS
personnel to report suspected abuse to proper
authorities.

Bryan E. Bledsoe
Richard A. Cherry
Robert S. Porter
Duty to Report
• Do not confront abuser.
• Not necessary for you to prove abuse or neglect
occurred before reporting.
• Failure to report abuse or neglect bigger liability
than reporting.

Bryan E. Bledsoe
Richard A. Cherry
Robert S. Porter
Documentation
• Well-documented Patient Care Report
– Completed promptly after patient contact
– It is thorough.
– It is objective.
– It is accurate.
– It maintains patient confidentiality.

Bryan E. Bledsoe
Richard A. Cherry
Robert S. Porter
Documentation
• Complete well-written patient care report is your
best protection in malpractice action.
• If patient care report incomplete or inaccurate, a
written amendment should be attached.
• Medical records maintained for period of time
prescribed by state law.

Bryan E. Bledsoe
Richard A. Cherry
Robert S. Porter
Figure 7-9 Template-driven electronic patient records are becoming more common in modern
EMS.

Bryan E. Bledsoe
Richard A. Cherry
Robert S. Porter
Employment Laws
• Employment laws:
– Address employee-employer relationships.
– Volunteer agencies fall under jurisdiction of many of
these laws.
– Can be complex.
– Consult attorney should problem arise.

Bryan E. Bledsoe
Richard A. Cherry
Robert S. Porter
Employment Laws
• Americans with Disabilities Act: prohibits
discriminating against qualified individuals with
disabilities.
• Title VII: federal law prohibits workplace
harassment and discrimination.

Bryan E. Bledsoe
Richard A. Cherry
Robert S. Porter
Employment Laws
• Amendments to Title VII
– Equal Employment Opportunity Act of 1972
– Age Discrimination and Employment Act of 1967
(ADEA)
– Age Discrimination Act of 1975

Bryan E. Bledsoe
Richard A. Cherry
Robert S. Porter
Employment Laws
• Family and Medical Leave Act of 1993 (FMLA)
• Fair Labor Standards Act of 1938 (FLSA):
minimum wage, overtime pay, record keeping,
child labor standards.
• Occupational Safety and Health Act (OSHA):
ensure employers provide healthy and safe
environment.

Bryan E. Bledsoe
Richard A. Cherry
Robert S. Porter
Employment Laws
• The Ryan White CARE Act: fund programs to
improve availability of health care for victims of
AIDS and their families.

Bryan E. Bledsoe
Richard A. Cherry
Robert S. Porter
Summary
• Paramedic's job: interaction with law enforcement
authorities; involvement in situations that give rise
to litigation.
• Learn and follow all state laws and local protocols.
• Receive good training.
• Keep current: continuing education programs and
conferences, industry journals, recertification or
relicensure.

Bryan E. Bledsoe
Richard A. Cherry
Robert S. Porter
Summary
• Always obtain informed consent before initiating
treatment and/or transport.
• Practice skills and procedures that reasonable
and prudent paramedic would, given same or
similar circumstances.

Bryan E. Bledsoe
Richard A. Cherry
Robert S. Porter
Summary
• Practice procedures you are trained to perform
and are directly authorized to perform by medical-
control physician or approved local standing
orders.
• Prepare accurate, legible, complete medical
records that thoroughly document EMS incident.

Bryan E. Bledsoe
Richard A. Cherry
Robert S. Porter
Summary
• Discuss patient information with only those who
need to know.
• Purchase and maintain malpractice insurance;
employer does same.
• Be nice to patients and their families.
• Act in good faith; use common sense.
• High-quality patient care and documentation are
best protection from liability.

Bledsoe v1 ch07_lecture

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