Medical, Legal, and Ethical Issues in Emergency Care

Emergency Care and Transportation of the Sick and Injured - Chapter 3: Medical, Legal, and Ethical Issues

Unit Summary

  • Objectives: Understand ethical responsibilities and medicolegal guidelines pertinent to the EMT.
  • Topics covered include:
    • Patient confidentiality
    • Consent to treat
    • Refusal of care
    • Advance directives
    • Organ donor systems and policies
    • Evidence preservation
    • End-of-life issues

National EMS Education Standard Competencies

  • Preparatory: Applies fundamental knowledge of the EMS system, safety/well-being of the EMT, medical/legal, and ethical issues to the provision of emergency care.

Medical/Legal and Ethical Topics Covered

  • Consent/refusal of care (pp 86–90)
  • Confidentiality (p 91)
  • Advance directives (pp 93–95)
  • Tort and criminal actions (pp 101–103)
  • Evidence preservation (p 105)
  • Statutory responsibilities (pp 103–104)
  • Mandatory reporting (pp 104–105)
  • Ethical principles/moral obligations (pp 106–107)
  • End-of-life issues (pp 95–97)

Knowledge Objectives

  1. Consent Definition: Define consent and how it relates to decision-making (p 86).
  2. Types of Consent: Compare expressed, implied, and involuntary consent (pp 87-88).
  3. Consent for Minors: Discuss consent by minors for treatment or transport (p 88).
  4. Forcible Restraint: Describe local EMS protocol for using forcible restraint (pp 89-90).
  5. Refusal of Treatment: Discuss the EMT’s role when a patient refuses treatment or transport (pp 90-91).
  6. Confidentiality and HIPAA: Describe patient communication, confidentiality, and HIPAA relationship (pp 91-92).
  7. DNR Orders: Discuss the importance of DNR orders and local protocols (pp 93-95).
  8. Signs of Death: Describe physical, presumptive, and definitive signs of death (pp 95-96).
  9. Organ Donor Management: Explain how to manage identified organ donor patients (p 97).
  10. Medical Identification Importance: Recognize the importance of medical identification devices (p 97).
  11. Standards of Care: Discuss scope of practice and standards of care (pp 98-100).
  12. Legal Duty to Act: Describe the EMT’s legal duty to act (p 100).
  13. Negligence and Assault Issues: Discuss issues of negligence, abandonment, assault and battery, kidnapping (pp 101-103).
  14. Reporting Requirements: Explain reporting requirements for specific situations (pp 104-105).
  15. Ethics and Morality: Define ethics and morality and discuss implications for the EMT (pp 106-107).
  16. EMT Responsibilities in Court: Describe EMT’s roles and responsibilities in court (pp 107-109).

Reading and Preparation

  • Review all instructional materials including Emergency Care and Transportation of the Sick and Injured, Chapter 3, and related presentations.
  • Review legal documents pertaining to prehospital care services and personnel, and consult local law librarians for information on medicolegal issues.

Support Materials

  • Lecture PowerPoint presentation
  • Case Study PowerPoint presentation
  • Local/state statutes, regulations, policies related to prehospital care:
    • EMT scope of practice
    • DNR orders
    • Policies for reporting abuse, crime, refusal of care, use of restraints

Enhancements

  • Direct students to Navigate.
  • Contact local organ donation coordinators for materials on organ donation process.
  • Engage local hospitals or medical associations for insights on medical ethics.
  • Facilitate discussions on court considerations regarding reports and records:
    • If an action isn’t recorded, it wasn’t performed.
    • Incomplete reports suggest inadequate emergency care.
  • Cultural Considerations: Discuss the emancipation of minors regarding consent.
  • Current Controversies: Legal complexities around minors' capacity to consent to medical care.

Teaching Tips

  • Relay local protocols on confidentiality, consent, advance directives, and related issues.
  • Be attentive to students' emotional responses in violent crime scenarios.
  • Encourage private discussions for sensitive topics. Role-playing scenarios for refusal and consent practices are beneficial.

Unit Activities

  • Research Paper: Analyze lawsuits against EMS to explore prevention strategies.
  • Student Presentations: Recent negligence lawsuits against EMTs.
  • Group Activities: Create scenarios around consent and end-of-life complications.
  • Medical Terminology Review: Define key terms and match with their definitions.

Lecture Introduction

A. Principles
  • Do no further harm.
  • Provide competent care within the scope and standard of care.
  • Be aware that even proper care can lead to litigation.
II. Consent
  • A. Definition: Consent is permission to render care.
  • B. Requirement: Patients must consent for treatment.
  • C. Refusal Right: Conscious, rational patients can refuse care.
  • D. Decision-Making Capacity: Factors for capacity include understanding, age, impairment, and pain.
  • E. Patient Autonomy: Patients' rights regarding health decisions.
  • F. Assessing Capacity: Consider intellectual competence, maturity, impairment, and understanding.
Types of Consent
  • Expressed Consent: Patient explicitly agrees to treatment after being informed (nature, risks, benefits, alternatives).
  • Implied Consent: Applies to unconscious patients; must be a life-threatening condition supporting the emergency doctrine.
  • Involuntary Consent: For mentally ill or incapacitated patients; may involve guardians.
    • Minors Consent: Typically given by parents, with some states allowing emancipated minors their rights.
    • Forcible Restraint: Procedures must adhere to local laws, ensuring the safeguards of formal authority are respected.
III. Right to Refuse Treatment
  • A. Adults: Have the right to refuse treatment even at risk of death.
  • B. Litigation: Calls with refusals are often scrutinized legally; follow protocols.
  • C. Documentation: Always assess and document a patient's decision.
IV. Confidentiality
  • A. Definition: Confidentiality involves protected information during patient communication (history, assessment, and treatment).
  • B. Breach Risks: Release of information without all necessary permissions can lead to legal consequences.
V. Advance Directives
  • A. DNR Orders: Permits non-resuscitation but not the withholding of treatment.
  • B. Legal Requirements: DNR must be signed and valid, specifying medical situations.
    • Includes POLST and MOLST documents guiding patient treatment pathways.
VI. Physical Signs of Death
  • A. Responsibility: Confirming death is a physician’s role.
  • B. Signs: Presumptive signs include no responsiveness, heartbeat, pulse, and reflexes. Definitive signs include physical anomalies like rigor mortis, lividity, and decomposition indications.
VII. Special Situations
  • A. Organ Donors: Treat as any other patient, uphold life until all possible medical interventions are exhausted.
  • B. Medical Identification: Important for identifying critical health information for patient treatment.
VIII. Scope of Practice
  • Defined by state law and protocols detailed by medical directors.
IX. Standards of Care
  • The expected behavior of a trained individual in similar circumstances defined by local customs, laws, professional standards, and textbooks.
X. Duty to Act
  • Indicates the EMT's legal obligation to provide care once an ambulance responds or treatment starts.
XI. Negligence
  • The failure to render appropriate care, illustrated by four necessary conditions in civil litigation.
XII. Abandonment
  • Stopping care unilaterally without proper transition of care to a qualified person is viewed as abandonment under legal standards.
XIII. Assault and Battery, and Kidnapping
  • Assault: Causing fear of harm. Battery: Unlawful touching. Kidnapping: Unwanted transportation, potential implications of legal liability.
XIV. Defamation
  • Liability for false statements harming reputation; importance of accurate report writing.
XV. Good Samaritan Laws
  • A safeguard for those providing non-compensated help in emergencies; conditions apply to invoke protections offered.
XVI. Records and Reports
  • Essential for maintaining legal integrity and aiding in transparent emergency medical care practices.
XVII. Special Mandatory Reporting Requirements
  • Obligations to report abuse, injuries from crimes, and various other mandated situations as outlined by state laws.
XVIII. Ethical Responsibilities
  • Responsibilities extend beyond legal duties; encompass moral conduct and bioethics-related dilemmas encountered in practice.
XIX. The EMT in Court
  • Potential roles in court as witnesses or defendants; importance of preparation and legal counsel support when involved in litigation.

Post-Lecture Assessment in Action

  • Assessment resources available in the Navigate course.