hello and welcome to chapter three medical legal and ethical issues of the emergency care and transportation of the sick and injured 12th edition after you complete this chapter in the related coursework you will understand the ethical responsibilities and medical legal directives and guidelines pertinent to an emt the mt approach to patient care relating to confidentiality consent to treat refusal of care and advance directives are going to be explained organ donor systems and policies evidence preservation and end of life issues are also discussed all right so let's get started the basic principle of emergency care is to do no further harm so a health care provider usually avoids legal exposure if he or she acts in good faith and according to an appropriate standard of care so even when emergency medical care is properly rendered though sometimes you may be sued by a patient seeking monetary compensation so let's talk about consent first consent is permission to render care and if a person a person must give you 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 so what this means is the patient can understand and process the information provided and the patient can make an informed choice regarding medical care so patient autonomy is the patient's right to make decisions about his or her own health so in determining a patient's decision-making capacity consider these factors so is the patient intellectual capacity impaired by mental limitation or dementia and is the patient of legal age so usually it's 18 years in most states is the patient impaired by alcohol drugs serious injury or illness and 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 and are there any apparent hearing or visual vision problems is there a language barrier or does the patient appear to understand what you're saying does the patient ask rational decisions that demonstrate an understanding of the information you are trying to share next we're going to talk about express consent and so with express consent the patient acknowledges he or she wants you to provide care and 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 rests benefits and alternatives to treatment as well as the potential consequences of refusing care next we're going to talk about implied consent so implied consent applies to patients who are unconscious or otherwise incapable of making a rational informed decision about care and so on this slide you'll see figure 3-1 when a serious threat to life exists and the patient is unconscious or otherwise unable to give consent the law assumes that the patient would give consent to care and transport to the hospital this is implied consent okay implied consent like i said only when a serious medical condition exists and should never be used unless there is a threat of life or limb so the principle of applied consent is known as the emergency doctrine it is a good idea to try and get some consent from a spouse or spouse or relative before treating a patient based on implied consent all right and then there's involuntary consent so involuntary consent applies to patients who are mentally ill in a behavioral crisis or developmentally delayed and so obtain consent from the garden guardian or conservator it is not always possible to obtain 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 medical facility and then when we talk about consent there's minors okay so we need to discuss that so the parent or legal guardian usually gives consent all right in some states though a minor can give consent um with these following cases so it could be an emancipated minor and this means a person who is under the legal age in a given state but otherwise uh because of other circumstances is legally considered an adult many states consider minors to be emancipated if they are married or if they are a member of the armed surface services or if they are parents themselves also school teachers and school officials officials may act in place of the parents 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 to treat the minor is implied just as it is with an adult and then you have forcible restraint so this is necessary for patients who are in need of medical treatment and transportation but are combative and present a risk of danger to themselves or others so forcible restraint is legally permissible and if the consult medical control for authorization and utilize law enforcement on the scene restrained without legal authority exposes you to potential civil and criminal penalties once applied do not remove restraints and route unless they pose a risk to the patient also consider calling als advanced life support backup to provide chemical pharmacologic restraint okay so we've talked about the different types of consents and now we're going to talk about the right to refuse treatment so 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 they can withdraw that from treatment at any time even if the result is death or serious understand though that calls involving refusal treatment are commonly litigated in the ems and require you to proceed very cautiously involve online medical control and document this consultation a patient parent or caregiver 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 ability of alternative treatments and the possibility of consequences of refusing treatment so when treatment is refused you must assess the patient's ability to make an informed decision ask and repeat questions assess the patient's answers observe the patient's behavior if the patient appears to be 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 the patient do not endanger yourself to provide care though 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 gain you should again encourage the patient parent or caregiver to permit treatment and to call for an ambulance if he or she has changed their mind or if the condition worsens worsen so advise patients parents and caregivers that they can call 9-1-1 back if they change their mind advise the patient parent or caregiver to contact his or her own physician as soon as possible ask the patient parent or caregiver to sign a refusal of treatment form and a witness should be present thoroughly document all refusals all right so we've talked about refusals and now we're moving into confidentiality so communication between you and the patient is considered confidential confidential information includes a patient's history assessment findings and the treatments provided if you inappropriately release this information you may be liable for breach of confidentiality which is disclosure of information without proper authorization so in most states records may be released only if the patient signs a release if a legal subpoena is present or if they need are needed by billing personnel okay so let's talk about hipaa and hipaa is the health insurance portability and accountability act of 1996. hipaa contains a section on patient privacy that strengthened privacy laws and so hipaa provides guidance on which types of information are protected the responsibility of health care providers regarding that protection and penalties for breaching that protection so hipaa considers all patient information you obtain in the course of providing medical treatment to the patient to be protected information so this is phi protected health information phi includes medical information and any information that can be used to identify that patient a failure to abide by the provisions of hipaa's laws can result in civil or criminal action against you in your agency the general public is often permitted by law to record identifying and protected patient information and images all right so of course next let's talk about social media and unless you are operating as an official spokesperson from your agency avoid logos uniforms vehicles and other markings that associate you with your agency while off duty conduct yourself with the same professionalism that you would while on duty respect your patients their friends and families bystanders colleagues and other organizations for which you work for in person and online recognize that free speech does not mean everyone has a right to say anything under any circumstances and without repercussions all right so now let's talk about some different directives and we'll talk about advanced directives next so you may respond to a call where a patient is dying from an illness and a do not resuscitate order dnr gives permission to withhold resuscitation do not resuscitate does not mean do not treat though even in the presence of a duet dnr you are obligated to provide supportive measures and so some of the supportive measures might include oxygen or pain relief and comfort to the patient who is not in cardiac arrest whenever possible each ambulance service should have a protocol to follow in these circumstances right so next is advance directives so a written document specifying medical treatment for a competent patient should he or she become unable to make decisions so most commonly used when the patient becomes comatose so often referred to as a living well or healthcare directive in general a valid dnr order must meet the following requirements okay so a dnr must have a clear statement of the decision of the patient's medical problem a dnr must have a signature of the patient or legal guardian it must have a signature of one or more physicians or other lice licensed health care provider and the dnr order with an expiration date must be dated within the proceeding 12 months to be valid okay so on this figure in this slide you're going to see it an example of a wallet size dnr order you may encounter physicians orders for sustaining treatment so in medical orders versus life-sustaining treatment m-o-l-s-t forms when caring for patients with terminal illnesses these orders these medical orders explicitly describe acceptable interventions for the patient they must be signed by an authorized medical provider to be valid and if you encounter these documents contact medical control for guidance and some patients may have name surrogates to make decisions for them when they can no longer make it on their own so these are called durable powers of attorney for healthcare or also known as healthcare proxies physical signs of death so next we're going to talk about determining the cause of death and that's a medical responsibility of a physician okay so presumptive signs of death though um include unresponsive to painful stimuli lack of crotted pulse or heartbeat an absence of chest rise and fall no deep tendon or corneal reflexes absence of pupillary activity no systolic blood pressure profound cyanosis and lowered or decreased body temperature now definitive signs of death okay so definitive signs of death are um obvious mortal damage so some type of decon decapitation dependent lividity so dependent lividity is blood settling to the lowest point of the body causing discoloration of the skin and so in the figure on this slide you could see that that the patient was um laying a supine in and to show the dependent lividity has been ruled onto its side okay also rigor mortis and that is stiffening of the body muscles caused by chemical changes within the muscle tissue this occurs between 2 and 12 hours of death so that is the second sign of death physical death and then you have algomoritas that's the cooling of the body until it matches the ambient temperature okay and then putrification or decon decomposition of body tissues which depending on the temperature conditions it usually occurs between 40 to 96 hours after death all right so medical examiner causes so involvement of the medical examiner depends on the nature and scene of death in most states the medical examiner or coroner in some states must be notified in the following cases okay so a person who is dead on arrival sometimes called dead on scene death without previous medical care or when the physician is unable to to state the cause of death so in any suicide any violent death or any poisoning known or s which is known or sus suspected and so that's when you're going to get the medical examiner involved okay also a death from an accident suspicion of a criminal act or any infant in child deaths the medical examiner are going to be involved so you should make every attempt to limit your disturbance of a scene involving a death if emergency care has to be initiated keep thorough notes of what is done or found okay all right so special situations and organ donors have expressed a wish to donate their organs okay because so consent is um uh information on the donor core card or driver's license treat potential organ donors the same as you would any other patient and your priority is to save the patient's life so remember that organs need oxygen okay and so this is a figure the figure on this slide shows a sample of an organ donor card all right so at medical identification insignia and these can come in the form of bracelets or necklaces maybe a keychain or a card indicating a dnr order an allergy or any other serious medical conditions that might be helpful in assessing and treating the patient so some patients wear medical bracelets and it could have a usb flash drive and this uh often stored as a pdf file that can be read on most computers the figure on the side displays an example of a medical identification bracelet all right so next we're going to talk about scope of practice and this outlines the care that you are able to provide usually is defined by a state law the medical director further defines the scope of practice by developing protocols or standing orders authorization of treatment to provide care is given by the medical director okay and so um you are going to have that authorization by the medical director it could either be online and this includes when you call into the hospital on the radio or a telephone or also offline and these are standing orders okay so standing orders and carrying out procedures outside the scope of practice may be considered negligence okay so just to reiterate medical director can give you online orders via the radio or telephone and offline via standing orders or protocol all right so standards of care what are these and this is the manner in which you must act or behave and that's called the standard of care it is defined as how a person with similar training would act under a similar circumstance so standards of care are established in many ways and the first one is it's a standard imposed by a local custom so how a responsibly prudent person with similar training and experience would act in a similar circumstance with a similar equipment and in the similar same place or similar place okay so that's imposed by a local custom then you have standards imposed by law and these standards of medical care can be imposed by state statutes ordinance is administration regulation or case law so be familiar with the particular legal standards in your state and then you have a standard of care that's established by professional or institutional standards and so these are recommendations published by organizations and societies that are involved in emergency care for example the american heart association standard for bls or cpr then you have specific rules and procedures of your ems agencies then you have standards imposed by textbooks okay and then you have them standards imposed by states and these could be medical practices acts so in some states the emt is except from licensure requirements of a medical practices act then you have certification and licensure so credentialing is established process to determine the qualifications necessary to allow allow people to practice in a particular profession or a function of an organization so emts may be licensed or certified all right so the next thing we're going to talk about is the duty to act okay so duty to act is an individual's responsibility to provide patient care so once your ambulance responds to a call or treatment has begun you have the legal duty to act in most cases if you're off duty and come upon a crash you are not legally obligated to stop and assist patients you must know local laws and policies pertaining to your duty to act now we're going to talk about negligence so 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 on duty factors must be present present for legal doctrine of negligence to apply and for a patient to prevail in a lawsuit against an ems service provider okay so you have to have all four of these you have to have a duty so the obligation to provide care then you have to have breach of duty so emt did not act within the accepted or responsible standard of care next you have to have damages so a patient must physically or physiologically harmed in some noticeable way then you have causation okay so um causation is a cause and effect relationship between a breach of duty and the damages suffered by the patient so all four of those have to be present for negligence to apply all right next we're going to talk about rey's spa locutor and that's an emt can be held liable under the theory if it can be shown that an injury has occurred so that the cause of the injury was in the control of the emt and that the injuries generally do not occur unless there is negligence okay so then we have negligence per se and that's a theory that can be used when the conduct of the person being sued is alleged to have occurred in clear violation of statute so for an example an emt performs an advanced life support skill that resulted in injury to the patient okay then you have torts and so that's a civil wrongs not within the jurisdiction of u.s criminal courts and examples include defamation of character and invasion of privacy all right next we're going to talk about abandonment and so abandonment is a unilateral termination of care by an emt without the patient's consent and without making any provisions for care to be continued by a medical profession who is competent to provide care for the patient so once care started 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 emergency department where you are dropping off the patient so obtain a signature on your patient record from the person accepting transfer of care at the hospital all right next we're going to talk about assault and battery and kidnapping okay so assault is unlawfully placing a person in fear of immediate bodily harm this includes treating or threatening to restrain a patient who does not want to be transported battery is unlawfully touching a person and that that includes providing medical care without consent kidnapping is seizing confining abducting or carrying away by force that includes a situation where a patient is transported against his or her will false imprisonment is unauthorized confinement of a person and serious legal problems may arrive in situations in which a patient has not given or resends consent for treatment and transport all right so understand that defamation is the communication of false information that damages a person's reputation the two types of defamation written is libel so written is liable and then spoken as slander so understand the two s maybe an s you can unders uh remember that so slander spoken all statements on your run report should be accurate relevant and factual okay so good samaritan laws and immunity good samaritan laws are based on a common law principle that when you reasonably help another person you should be you should not be held liable for errors or omissions that are made in giving care so to be protected though by provisions of the good samaritan law several conditions must generally be met okay so you must have acted in good faith and rendering care you rendered care without exception expectation of compensation okay and you acted within the scope of your training and you did not act in a grossly negligent manner so gross negligence um is you conduct conduct that constitutes a willingful or reckless disregard for a duty or standard of care okay so immunity statutes apply to ems systems that are not considered governmental agencies and sovereign immunity provides limitations on liabilities and is not complete all right so next we're going to talk about some records and reports so you should compile a complete and accurate record of all incidents involving sick or injured patients and such records is an important safeguard against legal complications so the court's perception of records and reports include if an action or procedure was not recorded on a written report it was not performed okay so remember that incomplete or untidy reports are evidence of incomplete and inexpert emergency medical care provided nymphsis is the national ems information system okay so this provides the ability to collect store and share standardized ems data throughout the united states so special mandatory reporting requirements so some states have a reporting obligation for health care providers and emergency responders including emts the following are all mandatory reporting requirements that may vary from state to state though so child abuse abuse of an elder can person or abuse of at risk adults are mandatory reporting also injury during commission of a felony or drug related injuries and childbirth or all mandatory reporting requirements attempted suicides dog bites certain communicable diseases assaults and domestic violence are also special mandatory reporting required sexual assault or rape exposures to infectious diseases transports of patients in restraints seen of a crime or the deceased are all mandatory reporting requirements all right so next we're going to talk about ethical responsibilities so in addition to legal duties emts have certain ethical responsibilities as health care providers ethics is a philosophy of right and wrong moral duties and ideal professional behavior so morality is a code of conduct affecting character conduct and consequence bioethics specifically addresses ethical issues that arise in the practice of health care emts will encounter ethical dilemmas that will require you to evaluate and apply ethical standards so these include your own and the those of the profession so 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 all right next we're going to talk about the emt in court and of course you don't ever want to end up in court but you can end up in court as either a witness or a defendant so the case could be either civil or criminal whenever your subpoena detestified in any court proceeding you should immediately notify your service director and legal counselor if you're our witness remain neutral during your testimony and review the run report before the court appearance as the defendant an attorney is required so the attorney is generally supplied by your service in a civil suit defenses may include statutes of limitations so the time within which a case is must be commenced governmental immunity generally applied to municipalities or 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 rentered and then contributory negligence so a legal defense that may be erased when the defendant feels that the conduct of the plaintiff somehow contributed to injuries or damages sustained by the plaintiff and then there's discovery so an opportunity for both sides to obtain more information to reach a better understanding of the case so discovery includes depositions and that's an oral request or for questions and then also includes interrogatories so that's a written request or question and then there's the trials so most cases are settled following the discovery phase during a settlement phase and do not go to trial um for those those that do go to trial several types of damages could be awarded so you could have consent cons compensatory damages and those are intended to compensate the plaintiff for the injuries here she is sustained and then punitive damages are intended to deter the defendant from repeating the behavior and are reserved for cases where the defendant has acted um reckless disregard or intentionally for the safety of the public so these damages are not commonly awarded in negligent cases okay all right in most cases if a judgment is rendered against you your service or its insurance carrier will pay the judgment any emt charge with a criminal offense should secure the services of a highly experienced criminal attorney immediately okay and that concludes chapter three next we're going to go over the um review questions okay see if we missed anything so you arrive at a 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 do you think express consent so also called actual consent is when the patient authorizes you to provide treatment and transport either verbally or non-verbally her holding her arm out is that non-verbal consent okay which is the following example of abandonment okay so that's when we're going to leave the patient with somebody less trained than us okay so an emt leaves the scene after a refusal emt transfers care in the department nope to a nurse amt transfers to paramedic or an amt so an advanced emt transfers to an um in emr and that's going to be it d okay so a lesser training was uh was transferred all right the unauthorized confinement of a person is called false imprisonment and so that's confinement the person without the legal authority or their consent okay so failure of an emt provide the same care as another emt with the same training is called and we know this is that's negligence right okay so c is negligence liable is the written remember and slander is the statement verbal okay an eight-year-old boy was struck by a car he's unresponsive and bleeding from his mouth the police officer tells you that he isn't able to contact the parents you should and we're going to continue to treat the child and transport as soon as possible because that's what we would think that they would want us to do right right it's implied consent an advanced directive is and what is an advanced directive well we know it's written document right and uh so let's see it is a written document i'm almost positive of um of what the provide the patient would um would want to be care provided okay so that was c which of the following patients is competent and can legally refuse ems care okay so no confusion a man who's staggering nope a conscious and alert patient who is in severe pain hmm um let's see what they say oh they say a conscious and alert even though they're in a lot of pain they can refuse okay you are treating a patient with an apparent emotional crisis after the patient refuses care 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 do we think oh my goodness um it is unlawfully placing a person in fear of immediate body bodily harm right so it is assault okay so an emt has a legal duty to act if he or she is what do you think it's paid for services um but is not on duty a volunteer is on duty and dispatched well i said all right there you go um paid or volunteer and last one which of the following statements about records uh and reports are false okay let's see so d your patient care report does not become a part of the patient's hospital report that's false because it does become a part of the patient's hospital report that this concludes chapter three medical legal and ethical issues and if you like this lecture go ahead and subscribe and like thanks