Chapter Three: Medical, Legal, and Ethical Issues (Emergency Medical Technician)

Consent

• Required from conscious adults; patients can refuse all/some care.
• Can be expressed (actual) or implied. Foundation: decision-making capacity.
• Decision-making capacity (healthcare term): patient's ability to make health care decisions.
• Competence (legal term): determinations made by a court.

Decision-making capacity (factors to consider)

• Impairment by mental limitation, dementia, alcohol/drugs, serious injury/illness, significant pain.
• Legal age (18+ in most states).
• Apparent hearing/visual problems, language barrier.
• Patient understanding and rational questions.

Types of consent

• Expressed consent (actual): patient explicitly acknowledges care/transport (verbal or nonverbal).
• Informed consent: includes explanation of treatment, risks, benefits, alternatives, and consequences of refusing.
• Implied consent (emergency doctrine): used when patient is unconscious/unable to consent, and the condition is life-threatening or limb-threatening.
• Involuntary consent: for mentally ill, developmentally delayed, or crisis patients; requires guardian/conservator or law enforcement consent.
• Minor consent: parents/legal guardians consent; implied in emergencies if unavailable. Emancipated minors may consent for themselves.
• “Logo parentis”: school officials may give emergency consent for minors when parents are unavailable.
• Do not delay care to interpret a power of attorney.

Expressed vs implied vs involuntary consent details

• Expressed consent: valid only if informed; significant for documentation.
• Implied consent: valid only for serious conditions; ends if patient regains capacity.
• Involuntary consent: requires guardian/legal authority; involve online medical control.

Refusal of treatment (right to refuse)

• Adults with decision-making capacity have the right to refuse, even if it results in serious injury/death.
• Raises potential liability; follow local policies and involve online medical control.
• Present information about risks, benefits, alternatives, and consequences of refusing.
• Documentation is critical: include assessment, treatment offered, risks, alternatives, and consequences; ensure patient understanding.
• Do not assume informed refusal if patient appears confused, delusional, or suicidal.
• Attempt persuasion up to three times; advise to call 911 if condition worsens or if they change their mind.
• Obtain patient and witness signatures on a refusal form; if refusal to sign, document thoroughly and inform medical control.

Confidentiality and HIPAA

• Confidentiality: communications between provider and patient are confidential.
• Protected Health Information (PHI): patient history, assessment, treatment; disclosed for treatment, payment, or operations.
• Minimum necessary rule: share only what is necessary.
• HIPAA: protects patient privacy; penalties for violations; all identifying info is PHI.
• Social media: avoid posting patient information; maintain professional conduct online.

Advance directives and end-of-life planning

• Advance directives: written documents specifying treatment if patient becomes unable to decide (e.g., living wills).
• Do not resuscitate (DNR) orders: permission not to resuscitate. Validity requires state-specific criteria (e.g., clear medical problem, patient/guardian signature, physician signature, expiration date within last $12$ months in some states).
• Physician orders for life-sustaining treatment (POLST)/Medical Orders for Life-Sustaining Treatment (MOLST): explicit instructions for interventions, signed by provider.
• Durable Power of Attorney for Health Care/Health Care Proxy: designates surrogates to make decisions. Do not delay emergency care to interpret.
• Do not resuscitate does not mean do not treat: provide supportive measures and comfort care.

Death and signs of death; special death scenarios

• Determination of death is a physician’s responsibility.
• Do not declare death in hypothermia until warm (survival reported as low as $64^{\circ}F = 18^{\circ}C$).
• Presumptive signs of death: severe trauma, known end-stage disease (may need additional evidence in some cases).
• Definitive signs of death: Obvious mortal damage (e.g., decapitation), dependent lividity (livor mortis), rigor mortis (stiffening, typically $2-12$ hours after death), algor mortis (cooling to ambient temperature), putrefaction (decomposition, $40-96$ hours after death).

Medical examiner / coroner involvement

• Notify for trauma, suspected criminal activity, unusual circumstances, DOA, unknown cause, violent/poisoning deaths, infant/child deaths.
• Medical examiner supersedes others on scene.
• Limit scene disturbance; preserve evidence if death is obvious or crime suspected.

Special situations: organ donation, medical identification, and scene management

• Organ donors: consent is voluntary (donor card/driver’s license). Preserve donor conditions to maximize organ viability (treat like any other patient requiring oxygen).
• Medical identification insignia: bracelets/necklaces/cards indicating history, medications, allergies, DNR status.
• Medical scope of practice: defined by state law; medical director defines protocols.
• Duty to act: EMS personnel have a duty to act in certain circumstances (on-duty response). Off-duty duty varies.

Standard of care and scope of practice

• Standard of care: level of care a reasonably prudent person with similar training would provide in similar circumstances.
• Influenced by scene safety, patient count, equipment, local customs, laws, and institutional protocols.
• Deviation from standards can lead to civil/criminal liability.
• Licensure and certification are state requirements.
• Duty to act: defined by statute or function; EMS personnel on-call have a duty.

Negligence and liability concepts

• Negligence: failure to provide the same care a reasonably trained person would under similar circumstances.
• Four elements of negligence:
  • Duty: obligation to provide care.
  • Breach of duty: failure to meet standard of care.
  • Damages: patient harm (physical/psychological).
  • Causation: breach caused damages (proximate causation).
• If all four elements exist: $ext{Duty} \land \text{Breach} \land \text{Damages} \land \text{Causation}$, liability may be found.
• Res ipsa loquitur: injury occurred under care and would not without negligence, even if exact cause is hard to prove.
• Negligence per se: liability if conduct clearly violated a statute (e.g., administering a drug outside scope).
• Abandonment: unilateral termination of care without proper transfer.
• Assault: placing someone in fear of imminent harmful contact.
• Battery: unlawful touching.
• False imprisonment: transporting against patient’s wishes.
• Defamation: false statements harming reputation (libel = written, slander = spoken).
• Good Samaritan laws: protect off-duty responders rendering care in good faith (immunity varies by state).
• Official immunity/Sovereign immunity: protection for government entities/officials; not absolute for gross negligence.

Records, reporting, and quality assurance

• Records and reports: essential; “if it’s not documented, it wasn’t performed.”
• Support QA programs and research (NEMSIS – National EMS Information System).
• Many states require reporting of abuse, injuries from crime, births outside facilities, attempted suicides, domestic violence, sexual assault, and certain communicable diseases.
• Scene of a crime: preserve evidence; coordinate with law enforcement; avoid disturbing bullet holes.

Ethical responsibilities and decision-making

• Ethics: philosophy of right and wrong; applied ethics aligns actions with professional standards and patient welfare.
• Balance personal morals with professional standards; involve online medical control for dilemmas.
• Professional responsibility: honesty, confidentiality, reporting misconduct/errors.
• Unethical behavior undermines public trust.

Decision-making framework in practice

• When faced with dilemmas: consider options/consequences, review past decisions/policies, evaluate greatest benefit, involve online medical control.
• Professional ethics override personal morals while on duty.

The EMS courtroom: litigation and testimony

• EMTs may appear as witnesses or defendants; notify agency leadership if subpoenaed.
• As a witness, stay neutral and present facts from reports.
• Civil cases: service may provide counsel; defenses include statute of limitations ($t \leq 3 \text{ years}$), immunity, contributory negligence (patient's actions contributed to injury).
• Most cases settle; if not, proceed to trial.
• Punitive damages: awarded for intentional/reckless misconduct (rare).
• Criminal exposure: EMTs can face criminal charges (theft, assault, DUI, manslaughter, drug offenses); a conviction can end practice. Seek experienced criminal counsel immediately.

Special topics: practical scenarios and examples

• Social media: avoid sharing patient information.
• Do not resuscitate scenarios: ensure written physician orders; if in doubt, resuscitate.
• Organ donation: preserve life support to maintain organ viability unless directed otherwise.
• Medical identification devices: use to inform patient history while protecting PHI.
• Scene safety: prioritize responder and patient safety; coordinate with law enforcement; preserve evidence.

Key numerical references and formulas (LaTeX)

• Statute of limitations (example): claim initiated within $t \leq 3 \text{ years}$ (varies).
• Hypothermia survival: as low as $64^{\circ}F = 18^{\circ}C$.
• Rigor mortis: $2-12$ hours.
• Putrefaction: $40-96$ hours.
• DNR validity: within last $12$ months in some states.
• Negligence elements: $\text{Duty} \land \text{Breach} \land \text{Damages} \land \text{Causation}$.

Quick reference: glossary of terms

• Autonomy: patient’s right to make own health decisions.
• Capacity/Capacity assessment: patient’s ability to understand/process info for a decision.
• Competence: legal determination by a court.
• Informed consent: consent with knowledge of risks, benefits, alternatives, consequences of refusing.
• Implied consent: emergency doctrine for unable patients.
• Expressed consent: explicit permission.
• Do Not Resuscitate (DNR): order not to resuscitate.
• POLST/MOLST: medical orders for life-sustaining treatment.
• Durable Power of Attorney for Health Care: surrogate decision-maker.
• HIPAA: protects patient privacy and PHI.
• NEMSIS: standardized EMS data collection.
• Res ipsa loquitur: negligence inferred from injury itself.
• Sovereign immunity: protection for government entities.
• Good Samaritan: legal protection for off-duty/non-compensated care in good faith.
• Abandonment: unilateral care termination without proper transfer.
• False imprisonment: restraining a patient without consent/legal authority.
• Defamation: false statements harming reputation; libel (written), slander (spoken).

Connections to broader principles

• Consistent with medical ethics: autonomy, beneficence, nonmaleficence, justice.
• EMS relies on balance of patient rights, public safety, legal frameworks, and ethical guidelines.