hi welcome back i'm sean holt with rc health services and this is chapter 3 for emt basic chapter 3 medical legal and ethical issues a basic principle of emergency care is to do no further harm a health care provider usually avoids legal exposure if he or she acts in good faith and according to an appropriate standard of care even when emergency medical care is properly rendered sometimes you may be sued by a patient seeking monetary compensation consent consent is permission to render care a person must give consent for treatment if the patient is conscious and rational and capable of making informed decisions he or she has the legal right to refuse care the foundation of consent is decision making capacity the patient can understand and process the information provided the patient can make an informed decision informed choice regarding medical care patient autonomy is the patient's right to make decisions about his or her health in determining a patient's decision-making capacity consider these factors is the patient's intellectual capacity impaired by limit mental limitation or dementia is the patient of legal age 18 years old in most states is the patient impaired by alcohol drugs serious injury or illness does the patient appear to be experiencing significant pain does the patient have a significant injury that could distract him or her from a more serious injury are there any apparent hearing or visual problems is there a language barrier and does the patient appear to understand what you're saying does the patient ask rational questions that demonstrate an understanding of the information you are trying to share express consent the patient acknowledges he or she wants you to provide care transport to be valid the consent that the patient provides must be informed consent which means that you explain the nature of the treatment being offered along with the potential risks benefits and alternatives to treatment as well as potential consequences of refusing treatment implied consent applies to patients who are unconscious or otherwise incapable of making a rational informed decision about care implied consent on applies only when a serious medical condition exists and should never be used unless there is a threat to life or limb the principle of implied consent is known as the emergency doctrine it is a good idea to try to get consent from a spouse or relative before treating a patient based on implied consent involuntary consent applies to patients who are mentally ill in a behavioral or psychological crisis or developmentally delayed obtain consent from the guardian or conservator it is not always possible to obtain such consent so understand your local provisions for example many states have protective custody statutes that allow such a person to be taken under law enforcement authority to a medical facility minors and consent the parent or legal guardian gives consent in some states a minor can give consent that can be an emancipated minor a person who is under the legal age in a given state but because of other circumstances is legally considered an adult or many uh states consider minors to be emancipated if they are married if they are members of the armed services or if they are parents teachers and school officials may act in place of parents in loco parentis and provide consent for treatment to injuries that occur in a school or camp setting if a true emergency exists and no consent is available the consent consent to treat the minor is implied just as with an adult forcible restraint this is necessary for patients who are in need of a medical treatment and transportation but are combative and present a risk of danger to themselves or others forcible restraint is legally permissible consult medical control for authorization and utilize law enforcement on the scene restraint without legal authority exposes you to potential civil and criminal penalties one supply do not remove restraints in route unless they pose a risk to the patient consider calling als backup to provide chemical pharmacologic restraint the right to refuse treatment adults who are conscious alert and appear to have decision-making capacity have the right to refuse treatment even if the result is death or serious injury can withdraw from treatment at any time even if the result is death or serious injury calls involve refusal of treatment involving refusal treatment are commonly litigated in ems and require you to proceed very cautiously involve online medical control and document this consultation a patient parent or caregiver's decision to accept or refuse treatment should be based on information that you provide your assessment of what might be wrong a description of the treatment you feel is necessary any possible risks of treatment the availability of alternative treatments the possible consequences of refusing treatment when treatment is refused you must assess the patient's ability to make an informed decision ask and repeat questions assess and rep the patient's answers observe the patient's behavior and if the patient appears confused or delusional you cannot assume that the decision to refuse is an informed refusal when in doubt providing treatment is much more defensible position than failing to treat a patient do not endanger yourself to provide care use the assistance of law enforcement to ensure your own safety before leaving the scene where a patient parent or caregiver has refused care you should again encourage the patient parent or caregiver to permit treatment and to call for the ambulance if he or she has a change in mind or his all his or her condition worsens advise patients parents or guardians that they can call 9-1-1 back if they change their mind advise the patient parent or caregiver to contact his or her physician as soon as possible ask the patient parent or caregiver to refuse a to sign a refusal or treatment form a witness should be present for this and thoroughly document all refusals confidentiality communication between you and the patient is considered confidential confidential information includes patient history assessment findings and treatment provided if you inappropriately release information you may be liable for breach of confidentiality which is disclosure of information without proper authorization in most states records may be released only if the patient signs the release if a legal subpoena is presented or if they are needed by building personnel confidential information includes patient history assessment findings treatment provided if you inappropriately release information you may be liable for breach of confidentiality which is the disclosure of information without proper authorization uh health insurance portability and accountability act of 1996 hippa with a two a's at the end h-i-p-a-a contains a section on patient privacy that strengthens privacy laws hipaa provides guidance on which types of information is protected the responsibility of health care providers regarding that protection penalties for breaching that protection hipaa considers all patient information you obtain in the course of providing medical treatment to a patient to be protected health information phi or protected health information includes medical information and any information that can be used to identify the patient [Music] failure to abide by the provisions of hipaa laws can result in civil and or criminal criminal actions against you or your agency and possibly your agency the general public is often permitted by law to record identifying and protected patient information and images social media unless you are operating as an official spokesperson for your agency avoid logos uniforms vehicles or other markings that associate you with your agency while off duty conduct yourself with the same professionalism that you do while on duty respect your patients their friends and family bystanders colleagues and the organization for which you both work for which you work both in person and on online recognize that free speech does not mean everyone has a right to say anything under any circumstances and without repercussions advanced directives you may respond to a call where a patient is dying from an illness a do not resuscitate order or dnr gives us gives permission to withhold resuscitation do not resuscitate does not mean do not treat even in the presence of a dnr order you are still obligated to provide supportive measures such as oxygen pain relief and comfort to a patient who is not in cardiac arrest whenever possible each ambulance service should have a protocol and to follow in these circumstances a written document specifically medical specifying medical treatment for a competent patient should he or be she begun in a he or she become unable to make decisions excuse me most commonly used when a patient becomes comatose often referred to as a living will or health care directive in general a valid dnr order must meet the following requirements clear statement of the patient's medical problems signature of the patient or legal guardian signature of one or more physicians or other licensed healthcare providers and the dnr orders with expiration dates must be dated in the preceding 12 months to be valid the figure on this slide displays an example of a wallet-sized dnr order you may encounter physician orders for life-sustaining treatment p-o-l-s-t and medical orders for life sustaining treatment molst forms when caring for patients with terminal illnesses these medical orders explicitly describe acceptable interventions for the patient they must be signed by an authorized medical provider to be valid if you encounter these documents contact medical control provide for guidance some patients may have named surrogates to make decisions for them when they can no longer make their own durable power of attorneys for health care also known as health care proxies physical signs of death determination of the cause of death is the medical responsibility of a physician presumptive signs of death unresponsive to painful stimuli lack of a carotid pulse or heartbeat absence of a chest of chest rise and fall and no deep tendon or corneal reflexes absence of pupillary reactivity no systolic blood pressure profound cyanosis and lowered or decreased body temperature definitive signs of death can be obvious mortal damage such as decapitation and dependent lividity blood settling to the lowest point of the body causing discoloration of the skin rigor mortis a stiffening of the body muscles caused by chemical changes within muscle tissue this occurs between 2 and 12 hours after death algar mortis cooling of the body until it matches the ambient temperature in putrefaction or decompo decomposition of body tissues which depending on temperature conditions occurs between 40 and 96 hours after death medical examiner cases involvement of the medical examiner depends on the nature and scene of the death in most states the medical examiner or the coroner in some states must be notified in the following cases a patient who is dead on arrival some sometimes called dead on scene death without previous medical care or when the physician is unable to state the cause of death suicide violent death poisoning known or suspected death from accidents suspicion of criminal of a criminal act infant and child deaths you should make every attempt to limit your disturbance of a scene involving a death if emergency medical care has been initiated keep thorough notes on of what was done or found special situations organ donors organ donors have expressed a wish to donate their organs consent is evidenced by information on a donor card or driver's license treat potential organ donors the same as any other patient your priority is to save the patient's life remember that organs need oxygen the figure on this slide shows a sample organ donor card medical identification insignia bracelet necklace keychain or card indicating dnr order allergies or other serious medical condition that might be helpful in assessing and treating the patient some patients wear medical bracelets with a usb flash drive often stored as a pdf file that can be read on most computers the figure on this slide displays an example of a medical identification bracelet scope of practice outlines the care you are able to provide usually defined by state law the medical director further defines scope of practice by developing protocols or standing orders authorization to provide care is given by medical director via telephone or radio which is online or by standing orders of protocols offline carrying out procedures outside of the scope of practice may be considered negligence standards of care the manner in which you must act or behave is called the standard of care it is defined as how a person with similar training would act under similar circumstances standard of care is established in many ways uh standards imposed by local custom how a reasonable prudent person with similar training and experience would act under similar circumstances with similar equipment and in the same or similar place standards imposed by law standards of emergency care emergency medical care may be imposed by statutes ordinances administrative regulation or case law be familiar with the particular legal standards in your state professional or institutional standards recommendations published by organizations and societies that are involved in emergency medical care for example the american heart association's standard for bls and cpr specific rules and procedures of your ems agency in the the standards imposed by textbooks almost all textbooks follow the standards established by the national highway traffic safety administration or nhtsa local protocols or state standards may differ always follow your local protocols medical practices act in some states the emt is exempt from the licensure requirements of the medical practices act certification and licensure credentialing is an established process to determine the qualifications necessary to be allowed to practice a particular profession or to function as an organization emts may be licensed or certified duty to act duty to act is an individual's responsibility to provide care once your ambulance responds to a call or treatment has begun you have a legal duty to act in most cases if you are off duty and come upon a crash you are not legally obligated to stop and assist patients know your local laws and policies pertaining to your duty to act negligence negligence is a failure to provide the same care that a person with similar training would provide in the same or similar situation all four of the following factors must be present for the legal doctrine of negligence to apply and for a plaintiff to prevail in a lawsuit against an ems service or provider one duty the obligation to provide care two breach of that duty the emt does not act within an expected and reasonable standard of care three damages a patient is physically or psychologically harmed in some noticeable way and four causation a cause and effect relationship between a breach of duty and the damages suffered by the patient res ipsa locator an emt can be held liable under this theory if it can be shown that an injury occurred that the cause of the injury was in the control of the emt and that such injuries generally do not occur unless there is negligence and negligence per se a theory that can be used when the conduct of the person being sued is alleged to have occurred in violation of a statute an example an emt performs an als skill that resulted in injury to the patient torts these are civil wrongs not within the jurisdiction of u.s criminal courts uh examples include defamation or kev of character and invasion of privacy abandonment abandonment is the unilateral termination of care by the emt without the patient's consent and without making any provisions for care to be continued by a medical profession professional who is competent to provide care for the patient once care started you might you have assumed a duty that must not stop until an equally competent medical provider assumes responsibility abandonment may take place at the scene or in the emergency department where you are dropping off your patient obtain a signature on your patient care record from the person accepting transfer of care at the hospital assault battery and kidnapping assault the unlawfully placing a person in fear of immediate bodily harm includes threatening to restrain a patient who does not want to be transported and battery unlawfully touching a person includes providing emergency care without consent kidnapping seizing confining abducting or carrying away by force could include a situation where a patient is transported against his or her will false imprisonment is the unauthorized confinement of a person serious legal problems may arise in which in the situations in which a patient is not given or rescinds consent for treatment or transport defamation uh defamation the communication of false information that damages a person's reputation libel is written slander is spoken all statements on your run report should be accurate relevant and factual [Music] good samaritan laws and immunity good samaritan laws are based on the common law principle that when you reasonably help another person you should not be held liable for errors or omissions that are made in given in giving care to be protected by provisions of good samaritan law several conditions must generally be met you acted in good faith and rendering care you rendered care without expectation of compensation you acted within the scope of your training and you did not act in a grossly negligent manner gross negligence conduct that a conduct that a that constitutes a willful or reckless disregard for duty or standard of care immunity statutes apply to ems systems that are not considered governmental agencies sovereign immunity provides limitations on liability and is not complete records and reports you should compile a complete and accurate record of all incident incidents involving sick or injured patients such a record is an important safeguard against legal complications the court's perception of records and reports if an action or procedure was not recorded with on the written report it was not performed it was not performed incomplete or untidy reports are evidence of incomplete or inexpert emergency medical care national ems information systems or n-e-m-s-i-s provides the ability to collect store and share standardized ems data throughout the united states special mandatory reporting requirements most states have a reporting obligation for health care providers and emergency responders including emts the following special mandatory report reporting requirements may vary from state to state child abuse abuse of an older person abuse of another at-risk adult injury during commission of a felony drug relate excuse me drug related injuries and childbirth attempted suicides dog bites certain communicable diseases assaults and domestic violence sexual assault or rape exposures to infectious diseases transport of patients and restraints scenes of a crime in the deceased ethical responsibilities in a bet in addition to legal duties emts have certain ethical responsibilities as health care providers ethics is the philosophy of right and wrong moral duties and ideal professional behavior morality is the code of conduct affecting character conduct and conscience bioethics specifically addresses ethical issues that arise in the practice of healthcare emts will encounter ethical dilemmas that will require you to evaluate and apply ethical standards this could be of your own ethical standards or those of the profession applied ethics is the manner in which principles of ethics are incorporated into professional conduct allow rules laws and policies to guide your decision making the emt in court you can end up in court as a witness or a defendant and the case could be either criminal or civil whenever you are subpoenaed to testify in any court proceeding you should immediately notify your service director and legal counsel as a witness remain neutral during your testimony review the run report before your court appearance as a defendant an attorney is required the attorney is generally supplied by your service in the civil suit defenses may include statute of limitations the time within which a case must be commit must be commenced government governmental immunity generally applied to municipalities or other governmental entities if your service is covered by immunity it may mean that you cannot be sued at all or that it would limit the amount of monetary judgment recovered contributory negligence a legal defense that may be raised when the defendant feels that the conduct of the plaintiff somehow contributed to injuries or damages sustained by the plaintiff by the plaintiff excuse me discovery an opportunity for both sides to obtain more information to reach a better understanding of the case discovery includes interrogatories written requests or questions and depositions oral requests or questions [Music] trial most cases are settled following the discovery phase during a settlement phase and do not go to trial for those that go to trial several types of damages may be awarded compensatory damages are intended to compensate the plaintiff for the injuries he or she sustained punitive damages are intended to deter the defendant from repeating the behavior and are reserved for cases where the defendant has acted intentionally or with a reckless disregard for the safety to the public these damages are not commonly awarded in negligence cases in most cases if a judgment is rendered against you your service or its insurance carrier will pay the judgment in any emt charged with a criminal offense should secure the services of a highly experienced criminal attorney immediately review uh uh question one you arrive at the scene of an older woman complaining of chest pain in assessing her she holds her arm out for you to take her blood pressure this is an example of what and the correct answer is c expressed consent express consent also called actual consent is when the patient authorizes you to provide treatment and transport either verbally or non-verbally for example a patient who holds out his or her arm to allow you to take a blood pressure is non-verbally giving you expressed consent two which of the following is an example of abandonment okay the correct answer is d abandonment occurs when patient care is terminated without the patient consent patient's consent or when care is transferred to a provider of lesser training and level of certification number three the unauthorized confinement of a person is called what correct answer is c false imprisonment is defined as a confinement of a person without legal authority or the person's consent failure of the emt to provide the same care as another emt with the same training is called what the answer is c an emt could be held liable for negligence if he or she fails to provide the same care as another emt with the same training uh as another i'm sorry if he or she fails to provide the same care as another emt with the same training would provide in the same situation for example if an emt fails to give oxygen to a patient with shortness of breath an intervention that is clearly indicated he or she may be held liable for negligence an eight-year-old boy was struck by a car is unconscious and is bleeding from the mouth a police officer tells you that he is unable to contact the child's parents you should correct answer is a the child in this scenario is critically injured and requires immediate treatment and transport waiting until his parents are contacted wastes time and increases his chance of negative and negative outcome if you are unable to contact a minor's parents or legal guardian you should proceed with care based on the law of implied consent number six an advance directive is and the correct answer is c an advanced directive is a written document signed by the patient and a witness that specifies the medical care that should be provided if the patient loses decision-making capacity here for example if he or she is no longer deemed competent seven which of the following patients is competent and can legally refuse ems care correct answer is c a patient who is of legal age 18 in most states is conscious and alert to person place time and event likely has decision making capacity and can legally refuse ems care however patients who are confused possibly intoxicated or delusional are not capable of making rational decisions therefore you should provide care based on the law of implied consent number eight you are treating a patient with an apparent emotional crisis after the patient refuses treatment you tell him that you will call the police and have him restrained if he does not give you consent your actions in this case are an example of what the correct answer is a unlawfully placing a person in fear of immediate bodily harm for example having him restrained without his consent con constitutes assault number nine the emt has a legal duty to act if he or she is what correct answer is going to be b the emt paid or volunteered volunteer is has a legal duty to act if he or she is on duty and is dispatched on a call regardless of the nature of the call if the emt is off duty and or out of his or her jurisdiction he or she has a moral obligation to act but not necessarily a legal one number 10 which of the following statements about records and reports is false [Music] correct answer is d the statement your patient care report does not become a part of the patient's hospital record because your treatment was provided outside the hospital is incorrect your patient care report does in fact become a permanent part of the patient's hospital record all right that's it for chapter three thanks for tuning in again my name is sean holt with rc health services until next time