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EMS Legal and Ethical Considerations

Restraints

  • Soft restraints are preferred to prevent soft tissue damage.
  • Law enforcement and medical control should be involved.
  • Once applied, restraints should not be removed, even if the patient becomes cooperative.
  • Consider ALS for chemical restraint if necessary because some medications can be extremely helpful for calming these people down.

Patient Refusal

  • If a patient wants to stop treatment mid-transport, and wants to get out of the ambulance, technically, you have to let them out.
  • It is important to get them to a safer place.
  • Have the patient sign a refusal form, witnessed by a third party (family member, law enforcement, fire department).
  • If only you and your partner are available, you and your partner can witness the form.
  • Assess confused or delusional patients thoroughly; they must know where they are, what day it is, and what's going on.
  • When in doubt, provide treatment.
  • There will be less legal consequence, less withholding treatment with a question of infection.
  • Convincing some patients (e.g., farmers, ranchers) to accept transport can be challenging.
  • Explain the potential consequences of refusal, including serious heart damage or death.
  • Be honest about the potential for death if treatment is refused.
  • Offer alternatives, such as having a family member provide transport. If anything changes, pull over and call 911.
  • Document refusals thoroughly for legal protection.

Confidential Information

  • Patient name, history, and treatment details are confidential.
  • The media should be directed to law enforcement for information.
  • Information can only be disclosed if:
    • The patient signs a release.
    • A legal subpoena is presented.
    • It's needed for billing purposes.
  • Share information on a need-to-know basis.
  • HIPAA primarily concerns patient confidentiality in the EMS setting.
  • Violations can lead to termination and legal trouble.
  • Example: Law enforcement sharing photos from the Kobe Bryant crash faced job loss and prosecution.
  • Avoid posting anything on social media that ties you to your particular agency or any other agency, vehicles, those types of things.
  • Maintain professional conduct off duty.

Advanced Directives

  • Legal documents stating a patient's wishes (e.g., DNR - do not resuscitate).
  • A DNR does not mean "do not treat," only to not do CPR if the patient goes into cardiac arrest.
  • Specify desired treatments or appoint a medical authority (family member) to make decisions if the patient declines.
  • For a DNR to be valid, it must be in place, the document has to be dated, signed by the patient, signed by the physician, It physician, and has to state the medical condition.
  • Without a valid DNR, CPR must be initiated.
  • In situations where a DNR is not available but family opposes resuscitation, contact medical control for guidance.
  • Medical control conversations are recorded for legal protection.
  • If the family wants resuscitation despite a DNR, honor the DNR but seek legal guidance and medical control.

DNR Requirements

  • Must be dated and signed by the patient and physician.
  • The person in charge of their health care couldn't do it.
  • Must state the medical condition.
  • Health care directive: Where you state in a document what you do and don't want done in the case of, like, cardiac arrest.
  • Assigning a health care proxy (durable power of attorney for health care) allows someone else to make decisions.
  • Consider family wishes, but a valid DNR should be honored.

POST

  • Physician Ordered Scope of Treatment, that's a POST form for Idaho, used to specify life-sustaining treatments.

Hospice

  • More common for patients to die at home with hospice care.
  • Hospice nurses provide care and pain medication.
  • Families may still call 911 for emotional support.

Determining Death

  • Differentiate between definitive and presumptive signs of death.
  • Presumptive Signs of Death: Unresponsiveness, no pulse, no breathing, cyanosis.
  • Definitive Signs of Death: Lividity (blood pooling), rigor mortis (body stiffening), Algor mortis is cooling of the body until it matches the ambient temperature, putrefaction (decomposition).
  • Lividity: Blood pools to the lowest point of the body.
    • Law enforcement can tell if the body's been moved because the lividity will be in a certain spot.
  • Rigor Mortis: Body stiffens 2-12 hours after death.
  • Algor Mortis: Body cools to ambient temperature.
  • Putrefaction: Decomposition, occurring rapidly in warm environments.
  • In cases of death, involve the coroner or law enforcement.
  • Coroners investigate medical problems, events surrounding death, circumstances, and medications to determine if a crime has been committed.
  • Autopsies are performed if death is suspicious or violent such as deaths without previous medical care, deaths via suicide, violent deaths, poisoning or a suspected death, or infected children.

Organ Donation

  • Priority is always to save the patient's life.
  • Hospitals will determine organ donation eligibility.
  • Organs needing oxygen (brain, heart, kidneys) must be harvested quickly.
  • Other tissues (skin, eyes, corneas) can be harvested later.

Medical Alert Tags

  • Look for medical bracelets or tattoos indicating DNRs, allergies, or medical conditions.
  • If there is no documentation supporting it, then CPR must be started before calling medical control.

Scope of Practice

  • Each agency has a scope of practice for different levels of personnel.
  • The medical director is the physician that oversees your particular agency's personnel and scope of practice, everything that that they do.
  • The are responsible for signing off on your protocols, what you are allowed to do just without calling and getting permission to do it.
  • Working outside your scope can be considered negligent.
  • Forcing someone to be transported against will can result in false imprisonment or kidnapping charges.
  • EMT's are expected to know the information from county protocols.

Standards of Care

  • Established by local customs, laws, and ethics.
  • Ethics: Scientifically questionable things, looking at what the science supports.
  • Morals, morals are kind of what we are raised with within our family.
  • CPR standards are produced by the American Heart Association and should be followed. The state, national, and textbook standards of care must be followed.

Certification vs. Licensing

  • Certification: National Registry certification states that you have met the minimum requirements.
  • Licensing: Apply to the state for license to practice needing affiliation with an agency in the state of Idaho.

Duty to Act

  • If you sign up for a shift, you have a legal obligation to be there.
  • Four components of negligence:
    • Duty to act.
    • Breach of duty.
    • Damages (injury or harm to the patient).
    • Causation (injury tied to your actions).
  • You must check your equipment and ambulance to prevent negligence.

Legal Terms

  • Res Ipsa Loquitur: Harm obvious, negligence is implied.
  • Malfeasance: Performing an act you are not authorized to do.
  • Misfeasance: Performing an act incorrectly that you are authorized to do.
  • Nonfeasance: Not performing an act, and you are required to do so.
  • Termination of care is not okay without patient consent and without providing continuing care.
  • Abandonment is a separate issue from negligence. It's when you show up and somebody needs help, but they're drunk and malicious and tell you to f off, and you're like okay.
  • Assault: Threatening verbally.
  • Battery: Physically touching because the patient is alert and oriented in able to review.
  • Libel and slander or are talking bad about somebody of one of your patients.

Good Samaritan Law

  • The Good Samaritan law is for just the layperson to stop and help in an accident.
  • It does not protect on-duty EMS personnel.
  • Immunity is not complete from getting subpoenaed, protect it the most time that your report is thorough and documents all the important stuff.

Mandatory Reporting

  • Any abuse of people of any age, injury during the condition of a felony, drug related injuries, childbirth, suicide and attempted suicide, dogfights, communicable disease, assaults, domestic violence.

Legal Roles

  • You can end up in court as a witness or a defendant, and if they do call you to go at court, you want to re consult with your legal representation usually with the prosecutor or the city attorney, and you can consult with them regarding anything about the case or your particular will in it.
  • You should just remain neutral when providing it in court with the facts of the incident.

Communication and Documentation

  • Approach a senior patient, introduce yourself.
  • Make eye contact.
  • Review situations.
  • Talk to young kids people up to elderly.
  • Resources that are needed.
  • Transferring care to the hospital with enough information of what they are getting.
  • Verbal communication, physical body language, and written communication which we've talked a little bit about.
  • Patient reports are a part of a permanent record.

Therapeutic Communication

  • Verbal and nonverbal.
  • Patients describe things in their own words.
  • Developing a rapport with patients.
  • Shannon Weaver communication model: Sender> thought>message>receiver decodes message>feedback from sender.
  • Closed loop communication: Have clear feedback so people know what you asked them to do is what they understood.

Communication Techniques

  • Eye contact, body language, posture, voice volume, don't yell at older people.
  • Culture differences, language barrier.
  • Ethnocentrism: Considering your own cultural values more important than those of the other people.
  • Cultural imposition force your values on somebody else.
  • Body language tells you a different story by a facial expression.
  • Be mindful of your posture and speak calmly and confidently.
  • Do not threaten a patient.
  • Interviewing techniques: A comforting technique.
  • Do not touch the torso of a patient.
  • Do not give someone false assurance.
  • Always be honest with the patients and tell them what is going on.
  • Try to be empathetic.
  • Make yourself aware of how they were involved in a stressful situation.
  • Avoid speaking a lot of medical terminology and speak above their level of understanding.

Communication with Children

  • Involve the kid do not talk only talk to the parents.
  • Make them feel like they are deciding what you're going to do with them.
  • Give them whatever control and power of the situation.
  • Be honest with your patience.
  • They need to be able to manage their own emotions and be able to read other people's emotions.
  • Make sure you are always calm.

Special Considerations

  • Kneel and get down to the child's level.
  • Ask them about their pets and what their names are and something they have with children.
  • With those that are hearing impaired, have to write things down to communicate.
  • Do not assume all impairments, use proper language as translator if required.

Communication with Hospitals

  • Notify them, who the agency with are, give information about the patient, so all the resources can be available.
  • Notify patient age complaint and medical history, the treatments, all that stuff needs to be told to the hospitals.

Patient Care Report

  • Written or electronic, must include the chief complaint, name, age, sex, and level of consciousness.
  • Document everything that you did and everything the patient stated about symptoms by their on set, what where they are, and everything else.
  • Paint the picture.

Scope Format

  • S: What everybody including the patient told you.
  • O: Your findings.
  • A: What you think is wrong.
  • P: Treatment transport and continue of care.
  • Document everything, treatments, refusals, and what hospital the patient turns into.

Radios and Telemetry

  • The portable radios are kept on the body the unit radio is in the ambulance.
  • The base station is a main radio and transmitter.
  • The are dispatchers that connect the emergency personal.
  • Important to key the mic and wait for a second before you talk.
  • With dead spots there is a repeater that can go on a Schaefer Butte by Bogus basin.
  • Telemetry the EKG that is sent. for a particular patient to the hospital prior to arriving.
  • Scanners can monitor Frequencies.
  • Simplex, duplex, and multiplex, with the push a button to talk here and let go here.
  • Be very professional on the radio.
  • Use cellphones for patient information.

Medical Control

  • Online Medical controls, where you communicate directly.
  • Offline medical control is a set of written records.
  • The physician duty.
  • You want to explain what you want to Administer of medication.