EH

Chapter 3: Medical, Legal, and Ethical Notes

Introduction

  • Basic principle of emergency care: do no further harm (nonmaleficence).
  • Legal exposure is usually avoided when the provider acts: in good faith and according to an appropriate standard of care.

  • Consent is permission to render care.

  • A person must give consent for treatment.

  • If the patient is conscious and rational, he/she has a legal right to refuse care.

  • Foundation of consent: decision-making capacity (the ability to understand information and make an informed choice).

  • Patient autonomy: the right of the patient to make decisions about his or her health.

  • Expressed Consent

    • The patient acknowledges they want you to provide care/transport.
    • To be valid, the patient must provide informed consent (treatment explained, risks and benefits discussed).

  • Implied Consent

    • Applies to patients who are unconscious or otherwise unable to make an informed decision.

  • Involuntary Consent

    • Applies to patients who are mentally ill, in a behavioral crisis, or developmentally delayed.
    • Obtain consent from a guardian or conservator when applicable.
    • Not always possible; understand local provisions.

Minors & Consent

  • Parent/legal guardian gives consent.
  • In some states, a minor can give consent.
  • Emancipated minors (e.g., married, serving in the armed services, or parents) may have adult status for consent.
  • Teachers & school officials may act in place of parents.
  • If true emergency exists & no consent is available: treat the patient. Consent is implied.

Forcible Restraint

  • Sometimes necessary with combative patients; legally permissible under medical control.
  • May require law enforcement.
  • Once applied, do not remove restraints en route unless they pose a risk to the patient.
  • Consider calling ALS backup to provide chemical/pharmacological restraint.

The Right to Refuse Treatment

  • Conscious, alert adults with decision-making capacity have the right to refuse.
  • Refusals are frequently litigated; involve online medical control and document the consultation.
  • 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 confused or delusional, you cannot assume the refusal is informed.
  • When in doubt, treat.
  • Before you leave a scene where a patient, parent, or caregiver has refused care:
    • Encourage the individual again to allow care.
    • Ask the individual to sign a refusal of care form.
    • A witness is valuable in these situations.
  • Document all refusals.

Confidentiality

  • Confidential information includes: patient history, assessments, treatment provided.

  • Information generally cannot be disclosed except with a signed release, or under specific legal circumstances.

  • HIPAA (Health Insurance Portability and Accountability Act of 1996): strengthens privacy laws and safeguards patient confidentiality; protected health information (PHI).

  • Failure to abide by HIPAA provisions can result in civil and/or criminal action.

  • The general public is often permitted by law to record identifying and protected patient information and images in some circumstances.

  • Social Media

    • Avoid agency logos, uniforms, vehicles, or other markings while off duty.
    • Conduct yourself professionally on and off duty.
    • Free speech does not grant absolute immunity for every statement; repercussions may apply.

  • Advance Directives

    • An advance directive specifies treatment if the patient becomes unconscious or unable to make decisions.
    • Do not resuscitate (DNR) orders indicate not to perform resuscitation, but do not imply a blanket refusal to treat.

Advanced Directives

  • ONR orders must meet following requirements:

    • Statement of the patient’s medical problems.
    • Signature of patient or legal guardian.
    • Signature of physician or health care provider.
    • Not expired.

  • Other names for advance directives: Living will, Health care directive.

  • POLST/MOLST (Physician/Medical Orders for Life-Sustaining Treatment):

    • Explicitly describe acceptable interventions for the patient.
    • Must be signed by an authorized medical provider.
    • Contact medical control for guidance.

  • Some patients may have named surrogates to make decisions for them (durable power of attorney for health care, health care proxies).

  • Hospice/home health considerations may require these directives.

  • Physical Signs of Death

    • A physician determines cause of death.
    • Presumptive signs: unresponsive to painful stimuli; absence of carotid pulse or heartbeat; absence of breath sounds; absence of eye movement; no deep tendon or corneal reflexes; no systolic blood pressure; lowered/decreased body temperatures; profound cyanosis.
    • Definitive signs: decapitation; dependent lividity; rigor mortis (2–12 hours after death);
    • Algor mortis: cooling of the body until it matches ambient environment; putrefaction (decomposition) occurs 40–96 hours after death.

Medical Examiner Cases

  • Involvement depends on the nature/scene of death.

  • Examiners are notified in cases of: dead on arrival (DOA); dead on scene (DAS); suicide; violent or poisoning; death without prior medical care; death from accidents; infant/child death.

  • Special Situations

    • Organ donors: suspicion of a criminal act may affect investigation; evidence such as organ donor card/driver’s license.
    • Priority is to save the patient’s life; organs require oxygen.
    • Medical identification insignia (bracelets, necklaces, key chains, or cards) indicating DNR, allergies, diabetes, epilepsy, etc.; some patients wear medical bracelets with a USB drive.

  • Scope of Practice

    • Outlines the care you are able to provide; usually defined by state law.
    • Medical director defines protocols and standing orders.
    • Carrying out procedures outside of practice may be considered negligence or a criminal offense.

Standards of Care

  • The manner in which you must act or behave.

  • You must be concerned about the safety and welfare of others.

  • Standards of care are established by:

    • Local custom and law (statutes, ordinances, administrative regulations, or case law).
    • Professional or institutional standards (e.g., American Heart Association CPR guidelines; textbooks; organizations like NHTSA).
    • Standards imposed by states (Medical Practices Act; certification; licensure; credentialing).

  • Duty to Act

    • An individual’s responsibility to provide patient care.
    • Duty to act applies once your ambulance responds to a call or once treatment is begun.

  • Negligence

    • Failure to provide the same care that a person with similar training would provide in similar circumstances.
    • All four elements must be present: Duty, Breach of duty, Damages, Causation.
    • Res ipsa loquitur: the case where the cause of injury is typically within the EMT’s control; injury would not occur without negligence.
    • Negligence per se: conduct that occurs in clear violation of a statute.

Torts

  • Civil wrongs:
    • Abandonment: unilateral termination of care by the EMT without patient’s consent or without provision for continuing care.
    • Abandonment may occur at the scene or in the emergency department; always obtain a signature on your patient care record.
    • Assault: unlawfully placing fear in a person of immediate bodily harm (e.g., restraint);
    • Battery: unlawfully touching a person (e.g., providing care without consent);
    • False imprisonment: transporting a patient against their will or confining them without lawful authority.
  • Defamation
    • Libel: written false statements that harm a person’s reputation.
    • Slander: spoken false statements that harm a person’s reputation.

Good Samaritan Laws & Immunity

  • If you reasonably help another person, you will not be held liable for errors or omissions under certain conditions:
    • Good faith
    • Without expectation of compensation
    • Within scope of practice
    • Did not act in a grossly negligent manner
  • Gross negligence: conduct that constitutes willful or reckless disregard.
  • Immunity Statutes apply to EMS systems that are considered governmental agencies.
  • Sovereign immunity provides limitations on liability but is not complete.

Records & Reports

  • Compile a record of all incidents involving sick/injured patients.

  • Important safeguard against legal complications; courts consider: action not recorded wasn’t performed; incomplete or untidy reports can indicate poor care.

  • National EMS Information System (NEMSIS): ability to collect, store, and share standardized EMS data; used to improve speed and accuracy of data collection.

  • Special Mandatory Reporting Requirements (most states):

    • Abuse of children, older people, and others; injury during the commission of a crime; drug-related injuries; child birth; attempted suicides; dog bites; communicable diseases; felony; assaults; domestic violence; sexual assault or rape; exposures to infectious disease; transport of patients in restraints; scene of a crime; the deceased.

  • Ethical Responsibilities

    • Ethics: philosophy of right and wrong, moral duties, and ideal professional behavior.
    • Morality: code of conduct affecting character, conduct, and conscience.
    • Bioethics: addresses issues that arise in practice of health care; requires evaluation and application of ethical standards; alignment with personal, professional, and policy rules.

  • The EMT in Court

    • EMT may appear as a witness or a defendant; most cases settled during discovery; if not settled, the case goes to trial.
    • Damages may include compensatory damages and punitive damages.
    • If called to testify, notify your service director; as a witness, remain neutral; legal counsel may review run reports.
    • As a defendant, an attorney is required; defenses may include statute of limitations, governmental immunity, contributory negligence.
    • Discovery allows both sides to obtain more information via interrogations and depositions (written questions and oral questions).

The EMT in Court: Practical Notes

  • Most cases settle after discovery; some proceed to trial.
  • Damages types:
    • Compensatory damages: monetary compensation for loss or injury.
    • Punitive damages: punish the defendant for egregious conduct.

Quick Review Questions (from the transcript)

  • 1. An adult patient who is conscious and rational has a legal right to refuse.
  • 2. The legal age to refuse care in most states is 18.
  • 3. Expressed consent means the patient acknowledges they want you to provide care.
  • 4. Implied consent is used when the patient is unconscious.
  • 5. Informed consent means you have explained the risks and benefits of treatment.
  • 6. Involuntary consent may be used when the patient is mentally ill.
  • 7. In loco parentis allows teachers/school officials to give consent for children.
  • 8. Emancipated minors are legally considered to be adults.
  • 9. Who can authorize forcible restraints? Medical command/control.
    1. Information can be released only if the patient signs a release, a legal subpoena is present, or if needed for billing information.
    1. Failure to follow HIPAA laws can result in civil and criminal action.
    1. The four requirements for a DNR are: a clear statement of the patient’s medical problems; signatures of patient/legal guardian; signature of physician; not expired. DNRs with expiration dates must be dated within 12 ext{ months} of expiration date.
    1. Physical signs of death include: lack of carotid pulse; reflexes absent; no deep tendon or corneal reflexes; profound cyanosis.
    1. Definitive signs of death include: decapitation; dependent lividity; rigor mortis (occurring 2-12\text{ hours} after death).
    1. Medical identification insignia can be found as a necklace, bracelet, card, or key chain.
    1. Scope of Practice is defined by state law.
    1. Standards of care refer to the expected level and quality of care provided.
    1. Duty to act is the obligation to provide patient care once on scene or after treatment begins.
    1. Negligence is the failure to provide the same care that a reasonably competent person would provide; the theory of res ipsa loquitur applies when negligence is presumed.
    1. Res ipsa loquitur describes a situation where the injury would not occur without negligence by the EMT.
    1. Abandonment is terminating care without consent or without arranging continuing care.
    1. Battery is unlawfully touching a person.
    1. Assault is unlawfully placing a person in fear of imminent bodily harm.
    1. False imprisonment is unauthorized confinement of a person.