Ch04 ppt
- 1. Chapter 4 Medical, Legal, and Ethical Issues
- 2. Medical/Legal and Ethics • Consent/refusal of care • Confidentiality • Advance directives • Tort and criminal actions • Evidence preservation • Statutory responsibilities National EMS Education Standard Competencies
- 3. Medical/Legal and Ethics • Mandatory reporting • Health care regulation • Patient rights/advocacy • End-of-life issues • Ethical principles/moral obligations • Ethical tests and decision making National EMS Education Standard Competencies
- 4. Introduction • Medical providers provide care under a set of laws affecting how patients must be treated. – Ethics – Laws © Brand X Pictures/Creatas
- 5. Introduction • Paramedics work within several laws. – Both federal and state • You must understand the laws and ethics related to emergency care. – Failure to perform your job can result in civil/criminal liability.
- 6. Introduction • Ethics – Deals with the study of the distinction between right and wrong • This text is only a framework. – Laws and obligations vary between states.
- 7. Medical Ethics • Two types – Personal – Professional • In cases where they conflict, you must put your personal ethics aside.
- 8. Medical Ethics • Medical ethics are related to the practice and delivery of medical care. – Your understanding of medical ethics must be consistent with the codes of your profession.
- 9. Medical Ethics • The Oath of Geneva – Drafted by the World Medical Association in 1948 – Taken by medical students after completion of their studies • Code of Ethics for Emergency Medical Technicians – Issued by the National Association of Emergency Medical Technicians in 1978 – Still in use – Pledge to a number of ethical codes
- 10. Medical Ethics • Your state, service, or company may have its own codes, policies, and rules. • The ICARE Program – Incorporates many of the finest qualities of EMS professionals • All codes stem from concern for patients.
- 11. Medical Ethics • Apply three basic ethical concepts when making a decision: – Do no harm. – Act in good faith. – Act in the patient’s best interest.
- 12. Medical Ethics • Paramedics must be accountable for their actions at all times. – Choose a mentor. • Professional ethics are also important. • Always be respectful of patients.
- 13. Medical Ethics • The ethics of your profession require: – A total commitment to acting in the best interest of your patient – To otherwise conduct yourself in a professional and ethical manner at all times
- 14. Medical Ethics • The most successful and fulfilled paramedics: – Are patient advocates – Engage in training and professional development – Put the good of the team first • You are responsible for the future of EMS.
- 15. Ethics and EMS Research • EMS practices have largely evolved from “grass roots” efforts. – Properly randomized, controlled studies are uncommon, but are emerging. • Remember, “do no harm.” – Seek further education.
- 16. Ethics and EMS Research • EMS care still relies on anecdotal experience. – Some procedures prove not to be helpful. • Conducting studies on patients without informed consent is an ethical dilemma. – How are researchers handing ethical debates?
- 17. The Legal System in the United States • Federal and state government make, administer, and interpret laws affecting paramedics. – Three branches of government
- 18. Types of Law • Two types of law govern paramedics in court: – Civil • Patient can sue for perceived injury – Criminal • State can prosecute for breaking a statute Courtesy of Oregon State Police.
- 19. Types of Law • Civil law – Concerned with establishing liability – Civil suit is a legal action of this sort • Most lawsuits result from vehicle crashes. • Criminal prosecution – Action taken by government against someone prosecutors believe violated a law
- 20. Types of Law • Most suits against EMS involve negligence. • Intentional tort claims may also be filed: – Assault – Battery – Libel or slander – False imprisonment © Dan Myers
- 21. The Legal Process • Begins when a complaint is filed • Process may take several years – Discovery period – Motions – Settlement process or trial
- 22. The Paramedic and the Medical Director • Relationship is complex • Paramedic must answer to: – Medical director – Licensing agency – Employer • Despite overlap, distinctions are important.
- 23. The Paramedic and the Medical Director • Legislation may require a medical director. – Supervises paramedic – Paramedic is not the medical director’s agent • Medical director may issue remedial requirements – Not responsible for disciplinary actions
- 24. The Paramedic and the Medical Director • Many paramedic activities require orders from a physician. – Online or offline • If conflicts arise, online medical control should resolve them. – Not the paramedic
- 25. Licensure and Certification • Terms often confused; generally: – Certification • Certain levels of credentials • Criteria met for minimum competency – Licensure • Privilege granted by government authority – Credentialing may also be adopted.
- 26. Discipline and Due Process • Licensing action may be taken if an infraction occurs. – Paramedic has a right to due process. • Notice • Opportunity to be heard
- 27. Medical Practice Act • Defines minimum qualifications of health service providers • Defines skills practitioners can use • Establishes means of licensure/certification – May also include relicensure requirements
- 28. Scope of Practice • Care paramedic may perform according to the state under its license or certification – Medical director may not permit paramedic to perform all skills/give all medications. • Practicing outside scope of practice is negligence or a criminal offense
- 29. Health Insurance Portability and Accountability Act • HIPAA – Stringent privacy requirements – Provides for criminal sanctions and civil penalties – Information can be disclosed: • For treatment • For payment • When authorized
- 30. Health Insurance Portability and Accountability Act • Special reporting situations: – Mandated reporting – Authorized data collection/research – Subpoenas • Privacy officer required – Ensures PHI is not released illegally
- 31. Health Insurance Portability and Accountability Act • Some states have patient confidentiality laws. – Confidentiality is part of the code of Ethics for Emergency Medical Technicians. • You must provide patients with a copy of your service’s privacy policy. • HIPAA also regulates electronic information.
- 32. Emergency Vehicle Laws • Most states have specific statutes. – Define emergency vehicle – Dictate what traffic should do • Emergency vehicles must be operated safely. – Most states have a higher standard for EMS. – If a crash occurs, EMS is usually at fault.
- 33. Transportation • Patients should be transported to hospital of their choice when possible/reasonable – Most EMS have protocols that direct transport. • Paramedics can be liable if patient: – Is transported to an unequipped facility – Is not transported and later deteriorates
- 34. Crime Scene and Emergency Scene Responsibilities • Use extreme caution. – Do not move or touch anything unless absolutely necessary. – Patient may carry evidence in rape cases. – Protect scene from contamination. – When in doubt, attempt resuscitation.
- 35. Mandatory Reporting • Each state has its own requirements. – Virtually every state has laws for reporting child and elder abuse. • Many states have immunity provisions. • Failure to report is a crime. – Know reporting requirements in your state.
- 36. Paramedic–Patient Relationships • Always do what is best for the patient. • Decisions should be based on standards of good medical care. – Not possible legal consequences
- 37. Consent and Refusal • You must obtain consent before providing care. To provide consent, a patient must: – Be of legal age – Possess decision-making capacity • Patients can refuse care.
- 38. Consent and Refusal • Informed consent – Must be obtained from every adult with decision making-capacity • To obtain informed consent: – Describe the problem and proposed treatment. – Discuss risks and alternatives. – Advise the patient of consequences of refusal.
- 39. Consent and Refusal • Expressed consent – A type of informed consent • Implied consent – Consent that is assumed when an adult is unconscious or too ill/injured to verbally consent • Involuntary consent is an oxymoron.
- 40. Decision-Making Capacity • Refusals must be informed. • Decision-making capacity is the ability of the patient to: – Understand information. – Process information. – Make a choice.
- 41. Decision-Making Capacity • If a conscious patient with decision-making capacity refuses treatment: – Cannot be treated without a court order – Consult with medical control. – Use your “people skills.”
- 42. Decision-Making Capacity • Patients who refuse treatment are not “bad.” – May not want to admit there is a problem – Have patient speak to medical control. • Maintain a courteous, sympathetic attitude. • Documentation is critical.
- 43. Decision-Making Capacity • Back up refusal forms with action. – Do everything you can to inform the patient. – Ultimately, respect his or her rights. • It may not be clear as to whether or not a patient has decision-making capacity.
- 44. Decision-Making Capacity • Generally, patients with altered mental status or unstable vital signs cannot refuse transport. – Know the criteria for establishing mental competence. • If the situation is life- threatening, transport. The Ascensia Contour Blood Glucose Meter. Photo courtesy of Bayer HealthCare LLC. © 2006 Bayer Healthcare LLC.
- 45. Decision-Making Capacity • Some states have emergency transportation statutes. – Protect paramedics making good-faith judgments about decision-making capacity • Psychiatric emergencies present problems. – Follow protocols.
- 46. Minors • Obtain consent from a legal guardian. – In loco parentis if guardian is unavailable • Notify law enforcement and medical control if a parent refuses necessary treatment. – State may assume custody
- 47. Minors • Emancipated minors – Treated as legal adults because of qualifying circumstances • Obtaining consent is a difficult skill. – Your expertise will build over time.
- 48. Violent Patients and Restraints • You can only use force in response to a patient’s force against you. – Do not enter an unsafe scene. • Only restrain medical patients who are a danger to themselves or others. © Jack Dagley Photography/ShutterStock, Inc.
- 49. Negligence and Protection Against Negligence Claims • No protection for gross negligence • Negligence occurs when: – There was a legal duty to the patient. – There was a breach of duty. – The failure to act was the proximate cause of injury. – Harm resulted.
- 50. Negligence and Protection Against Negligence Claims • Behaving according to established standards and procedures is the best protection. – Consider insurance coverage. • “Foreseeability” is one aspect of negligence. • Negligence is typically divided into three categories: – Malfeasance – Misfeasance – Nonfeasance
- 51. Elements of Negligence • Duty – Prescribed by law – Do no further harm to patient. – Obligated to respond to calls while working • Typically, not while off duty • Make sure appropriate personnel respond.
- 52. Elements of Negligence • Duty (cont’d) – Must perform within a standard of care when providing assistance – Cannot abandon the patient once care begins – Must maintain licensure or certification and skills – EMS systems can be held to a legal duty.
- 53. Elements of Negligence • Breach of duty – Standard of care • What a reasonable paramedic would do in a similar situation – Some states distinguish between ordinary and gross negligence. – Re ipsa loquitur or negligence per se may apply.
- 54. Elements of Negligence • Proximate cause – Improper action or failure to act caused harm • Harm – Usually physical injury – May also include emotional distress, loss of income, loss of spousal consortium, etc.
- 55. Abandonment • Termination of care without patient’s consent – Implies continuing need for treatment • Once you respond, you cannot leave until a provider with equal or higher training takes responsibility.
- 56. Abandonment • Complete a written report. • Some situations may not require transport but are not considered abandonment. – Medical director will provide protocols. – Generally, encourage transport. • Know your service’s protocols.
- 57. Patient Autonomy • Patients have the right to direct their own care – Almost every case – Respect and honor patient’s rights. • Regardless of perceptions of others • Even if patient’s death is result © UPI/HO/Landov
- 58. Patient Autonomy • Resolve ethical conflicts through communication. – If you disagree with a physician, discuss it. – Always act as a patient advocate. • You may need to treat a patient against his or her wishes.
- 59. DNR Orders • Describes which life-sustaining procedures, if any, should be performed – Laws differ between states. – May include a physician order or medical jewelry Courtesy of the MedicAlert Foundation ®. © 2006, All Rights Reserved. MedicAlert ® is a federally registered trademark and service mark.
- 60. DNR Orders • Generally, DNRs must: – Clearly state medical problem – Have patient/guardian signature – Have signature of one or more physicians • You must still provide supportive measures if a patient is not in cardiac arrest.
- 61. Withholding or Withdrawing Resuscitation • Relies on common sense, reasonable judgment • Consider: – Time to reach definitive care – Likelihood of survival • Rare survival cases should not guide your decisions.
- 62. Withholding or Withdrawing Resuscitation • Provide 15 minutes of best available method. – Stop if no extenuating circumstances exist. – Follow written protocols. • State laws vary. – State laws continue to govern your practice with deceased patients.
- 63. Withholding or Withdrawing Resuscitation • Halting resuscitation is especially difficult with pediatric patients. • Seek training, review literature, and have open discussions regarding resuscitation. – Understand consequences of interventions. – When in doubt, contact medical control.
- 64. End-of-Life Decisions • You will often deal with patients at the very end of their lives. – Treat with respect and empathy – Never question why help was called. • Providing information and support is part of your job.
- 65. End-of-Life Decisions • Avoid imposing your own moral code. – Respect patient’s wishes, even if you disagree. • You may encounter confusing scenarios. – Resuscitate until paperwork is confirmed. – Avoid hostile encounters with family members who disagree with the patient’s wishes.
- 66. End-of-Life Decisions • Medical orders for life-sustaining treatment (MOLST) – Similar to DNR, but more expansive – May apply with impending pulmonary failure – Guide use of CPR, intubation, feeding tubes antibiotics, palliative care
- 67. End-of-Life Decisions • Organ donation – Keeping a patient alive for an organ donation is a major ethical issue. – Understand state laws. – Attend workshops. – EMS plays a vital role in securing transplants.
- 68. Good Samaritan Legislation • Provides immunity from liability – Passed to encourage public to help – Some protection for EMS personnel • Does not apply while on duty – Legal duty applies • Must do all you can, within your knowledge
- 69. Ryan White Act • Provides safeguards and protections for health care workers exposed or potentially exposed to certain designated diseases – Notify your infection control officer if you believe you may have been exposed.
- 70. • Paramedics must understand law and ethics; failure may result in civil and/or criminal liability. • Professional ethics bind the paramedic. • Three primary ethical principles for paramedics are to do no harm, act in good faith, and act in the patient’s best interest. • EMS research presents ethical dilemmas regarding informed patient consent. Summary
- 71. Summary • The three branches of government are executive, judicial, and legislative. • Two types of law: civil and criminal • Paramedics are susceptible to assault and battery charges. • Restraining a patient against his or her will is false imprisonment. • Risks to paramedics: defamation, slander, libel
- 72. Summary • The lawsuit process: complaint, defendant response, discovery, settlement, trial • Paramedics are subject to multiple legal jurisdictions. • Paramedics are held personally responsible for their actions. • Directives from the medical director are binding, unless the paramedic believes they will cause harm.
- 73. Summary • State legislation allows paramedics to practice in every state. • Licensure is a privilege. • Paramedics have a right to due process. • The Medical Practice Act defines the scope of practice for the paramedic. • HIPPA protects patient information.
- 74. Summary • EMTALA prevents hospitals from turning away patients. • Emergency vehicle operation must be performed safely. • Transportation of a patient depends on preference and medical needs. • Paramedics must preserve evidence and document their actions at a crime scene.
- 75. Summary • Failure to report particular cases can result in legal action. • Some types of deaths must be reported to local law enforcement personnel. • Paramedics cannot infringe on the privacy, consent, and refusal from patients of sound mind. • The only protection against a civil suit over refusal is documentation.
- 76. Summary • Informed consent must be obtained prior to any medical process. • Expressed consent must be obtained prior to any treatment. • Implied consent exists when paramedics deem treatment is required for patients who cannot answer for themselves.
- 77. Summary • Determining the decision-making capacity of a patient can be tricky, but tools can provide factual documentation of patient ability to make clear decisions regarding his or her medical care. Thorough documentation and consultation with medical control will provide the best protection against lawsuits. • Minors cannot consent to care or refuse it; exceptions exist for emancipated minors.
- 78. Summary • Patients may be restrained if they are a danger to themselves or others. • Protocols and professional ethics take precedence over the personal feelings of the paramedic. • Negligence occurs when duty to act, breach of duty, proximate cause, and injury-related processes have occurred.
- 79. Summary • Negligence can be acts of commission or omission. • Paramedics cannot abandon their patients. • Documentation prevents the appearance of abandonment. • Patients have the right to determine their own care.
- 80. Summary • DNR orders define the care a patient wants when lifesaving procedures are required. • Paramedics need to become familiar with the choices their patients have made related to medical care and treatment issues. • Paramedics must address futile resuscitation efforts prior to an emergency event. • Good Samaritan laws protect the paramedic providing care off duty.
- 81. Summary • Governmental immunity may protect the paramedic who is not negligent. • The statute of limitations and contributory negligence are two common legal defenses. • The relationships between paramedics and their employers are affected by federal and state laws.
- 82. Credits • Chapter opener: © Mark C. Ide • Backgrounds: Blue—Jones & Bartlett Learning. Courtesy of MIEMSS; Green—Jones & Bartlett Learning; Purple—Jones & Bartlett Learning. Courtesy of MIEMSS; Red—© Margo Harrison/ShutterStock, Inc. • Unless otherwise indicated, all photographs and illustrations are under copyright of Jones & Bartlett Learning, courtesy of Maryland Institute for Emergency Medical Services Systems, or have been provided by the American Academy of Orthopaedic Surgeons.