Medical, Legal, and Ethical Issues
Medical, Legal, and Ethical Issues in Emergency Care
Introduction
The fundamental principle is to do no further harm.
Emergency Medical Technicians (EMTs) can significantly improve patient outcomes.
A strong understanding of medical, legal, and ethical considerations is crucial in emergency medical services (EMS).
Acting in good faith, adhering to standards of care, and showing compassion can help EMTs avoid legal issues.
EMTs are often the first point of contact in pre-hospital care.
As emergency medical care becomes more complex, litigation is likely to increase.
Providing competent care within the scope and standards helps prevent civil and criminal actions.
Ethical considerations are also important.
Scenarios and Ethical Questions
Examples of ethical dilemmas:
Treating patients at an accident scene while en route to another emergency.
Initiating cardiopulmonary resuscitation (CPR) on a patient with terminal cancer.
Treating a child with obvious signs of death because parents are pleading.
A patient wanting to be let out of the ambulance during transport.
Suspecting child abuse and a parent demanding you stop treatment.
A partner posting about an emergency call on social media.
Even with proper care, lawsuits may still occur.
Administrative actions, such as license suspension, can result from not following state EMS regulations.
Consent
Consent is generally required from conscious adults before starting care.
A person must give permission or consent for treatment.
Conscious, rational adults can refuse care even if ill or injured.
Patients can consent to some treatments while refusing others.
If a patient refuses, you cannot provide care; doing so can lead to criminal or civil action.
Consent can be expressed, actual, or implied.
The foundation of consent is decision-making capacity.
Decision-Making Capacity
Decision-making capacity: the patient's ability to understand and process information to make informed medical decisions.
Patients have the right to make medically unsound choices (patient autonomy).
Competence (legal term, determined by a court) vs. Decision-making capacity (healthcare term).
Factors affecting decision-making capacity:
Intellectual limitations or dementia.
Legal age (18 in most states).
Impairment by alcohol, drugs, injury, or illness.
Significant pain.
Distracting injuries.
Hearing or visual impairments.
Language barriers.
Ability to understand and ask rational questions.
Types of Consent
Expressed consent.
Implied consent.
Involuntary consent.
Expressed Consent
Expressed consent (actual consent): patient specifically acknowledges they want care.
Can be verbal (e.g., saying "yes" to blood pressure check) or nonverbal (e.g., nodding or extending an arm).
Must be informed consent:
Explanation of treatment nature, risks, benefits, and alternatives.
Consequences of refusing treatment.
Pre-hospital settings often require quick consent.
Paramedics provide more information for advanced life support due to potential side effects.
Verbal consent is valid but hard to prove; document consent in the report.
A witness can be helpful if consent is challenged.
Patients can agree to some care but not others.
Implied Consent
Implied consent: the law assumes unconscious or incapable patients would consent to care if able.
Applies to those intoxicated, mentally impaired, or with conditions like head injuries.
Also known as the emergency doctrine; only applies to serious medical conditions with a threat to life or limb.
Unclear situations may lead to legal proceedings; document efforts to obtain consent.
Efforts should always be made to obtain consent from a spouse, relative, or next of kin before relying on implied consent.
Never delay treatment for imminently life-threatening injuries.
Implied consent is no longer valid if the patient regains consciousness and can make informed decisions.
Involuntary Consent
Involuntary consent: involves patients with mental illness, developmental delays, or psychological crises.
Consent from a guardian or conservator is needed for mentally incompetent adults.
Many states have protective custody statutes allowing law enforcement to take the person to a medical facility.
Law enforcement/prison officials can give consent for incarcerated individuals, but conscious prisoners retain the right to refuse care.
Know local provisions and involve online medical control.
Minors and Consent
Minors require parental or legal guardian consent for treatment.
Emergency care can be given to a child without parental consent in every state when a parent cannot be reached.
In some states, mature minors can consent to medical care.
Emancipated minors can be treated as adults (e.g., married, in the military, parents, or living independently).
Know state laws on emancipation.
In school or camp settings, teachers/officials may act in loco parentis (in place of a parent) and give consent if parents are unavailable.
Always try to get parental consent if possible.
Never withhold lifesaving care for a minor if a person authorized to provide consent is unavailable.
Follow local protocol or consult medical control to determine if someone acting in loco parentis will need to accompany the child during transport and be present at the receiving hospital until a parent or guardian arrives.
Forcible Restraint
Forcible restraint: when a patient needs treatment/transport but is combative and poses a risk to themselves or others.
Consult medical control for authorization or contact law enforcement (in some states, only police can restrain).
Restraint without legal authority can lead to civil and criminal penalties.
Use restraint only when there is a risk to the patient or others.
If the patient poses a risk to the rescuer, wait for law enforcement to arrive.
Services should have defined restraint protocols.
Restraints are appropriate if the patient has a serious medical condition or behavioral disorder posing a risk.
Attempt verbal de-escalation before physical restraints.
Assess and document the patient's decision-making capacity.
Do not remove restraints en route unless they pose a risk, even if the patient promises to behave.
Use safe restraint strategies to minimize harm.
Ensure airway protection; monitor respiratory and circulatory status to prevent complications.
Consider advanced life support (ALS) backup for chemical restraint, which may be safer.
The Right to Refuse Treatment
Conscious, alert adults with decision-making capacity can refuse or withdraw from treatment (autonomy).
This right exists even if refusal may lead to death or serious injury.
Requires cautious handling and knowledge of local policies.
Involve online medical control and document the consultation.
The patient's decision should be based on provided information:
Assessment findings.
Necessary treatment description.
Treatment risks.
Alternative treatments.
Consequences of refusal.
Ensure the patient understands and encourage questions.
Include all information in the patient care report.
Many jurisdictions use preprinted refusal forms.
Assess the patient's ability to make an informed decision (ask questions, observe behavior).
Do not assume an informed refusal if the patient is confused or delusional.
Patients with suicide attempts or intent may not have normal mental capacity.
Consider the constellation of findings when determining capacity.
When in doubt, providing treatment is more defensible than failing to treat.
Contact medical direction if unsure; prioritize your safety and use law enforcement assistance if needed.
Before leaving, encourage treatment again (up to three times if possible).
Advise the patient to call 911 if their condition worsens or they change their mind.
Advise the patient to contact a personal physician as soon as possible.
Have the patient sign a refusal form; thoroughly document all refusals, assessments, efforts to obtain consent, and possible consequences.
Get a family member or police officer to witness the signature.
A refusal form doesn't guarantee protection against legal action but can help defend you.
Notify medical control of actions; medical control can help guide your decisions.
Parental refusal for a child requires consideration of emotional effects on the parent's judgment.
Try persuasion, and involve supervisors, ALS personnel, medical control, or law enforcement.
Obtain a signature on a release form; document findings, care, efforts, consultation, and responses.
Obtain a witness signature (preferably a police officer).
Retain documents with records for potential legal claims.
If the patient refuses to sign, inform medical control and thoroughly document the situation.
Parents refusing care for a child may face neglect charges; documentation must be thorough and accurate.
Your safety is the priority; don't endanger yourself while attempting to care for a refusing patient.
Confidentiality
Communication with patients is confidential and cannot be disclosed without permission or a court order.
Confidential information includes patient history, assessment findings, and treatment.
Unauthorized disclosure can result in liability for breach of confidentiality.
Records may be released with a legal subpoena or a patient's written release.
Sharing patient information with third-party billing personnel is not considered a breach.
Health Insurance Portability and Accountability Act (HIPAA)
HIPAA safeguards patient privacy of healthcare information.
Protected health information (PHI) includes medical and identifying information.
EMTs must protect PHI from unlawful disclosure (written or verbal).
departmental security measures prevent HIPAA violations:
No sharing passwords.
Proper disposal of documents.
Never leave electronic devices or patient reports that contain PHI unattended.
Maintain PHI when multiple patients are nearby.
Access to PHI of patients you didn't treat is only allowed for legitimate business reasons.
Do not access records of celebrities, family, or your own without permission.
PHI can be disclosed for treatment, payment, or operations.
Reporting assessment and treatment to other healthcare providers is permitted.
Use information for quality improvement/training after removing identifiers.
Legally mandated reporting (e.g., child abuse, subpoenas).
Release the minimum necessary information (except for treatment purposes).
Failure to comply with HIPAA can result in civil and criminal action against the agency and the individual.
Each EMS system must have a policy manual and a privacy officer.
Any sharing of private/protected information is a serious HIPAA and ethical violation -- even if done privately.
Information shared in face-to-face conversation or social media may feel private, but the information must remain between the patient and caregiver only.
Information may be used for education and quality improvement after removing identifying information.
The public is often permitted to record protected patient information and images. Responders and officers cannot generally interfere with the public.
Social Media
Unauthorized sharing of private/protected patient information is never permitted.
Sharing personal opinions on social media is complex.
If using agency-supplied equipment or during duties (including volunteering), the agency likely owns the content and may have to release it to the public upon request.
Association with the agency (logos, uniforms) may limit expressing private views compared to the general public.
General advice to avoid issues:
Avoid agency identification when off-duty unless you are operating as an official spokesperson for your agency.
Maintain online professionalism.
Respect patients, their families, bystanders, coworkers, and the organization.
Free speech does not mean you can say anything without repercussions.
Advance Directives
EMTs will encounter situations where patients are dying.
Without valid documentation (advance directive or Do Not Resuscitate (DNR) order), difficult situations may arise.
A competent patient can make well-being decisions.
Advance directive: written document specifying medical treatment if the patient becomes unable to make decisions (often when comatose).
Also known as a living will or healthcare directive.
Can include directions to withhold care, provide nutrition, or administer pain medication.
Do Not Resuscitate (DNR) orders give permission not to attempt resuscitation.
State laws vary; be familiar with your state's requirements to determine whether the DNR will be honored.
Valid DNR order requirements:
Clear statement of patient's medical problem(s).
Signature of the patient or legal guardian.
Signature of one or more physicians or other licensed health care providers.
In some states, DNR orders contain an expiration date and must be dated within the preceding 12 months to be valid.
Physician Orders for Life-Sustaining Treatment (POLST) or Medical Orders for Life-Sustaining Treatment (MOLST) explicitly describe acceptable interventions in the form of medical orders.
These forms must be signed by an authorized medical provider (physician, physician assistant, or nurse practitioner, varies by state) to be valid.
Consult medical control if you encounter these documents.
Durable power of attorney for healthcare or healthcare proxy: designating surrogates to make healthcare decisions if the patient is incapacitated.
Carefully read the power of attorney to ascertain its meaning and validity. There are different types of powers of attorney, and not all are authorized to exercise medical decision making.
If there's any question, contact online medical control for assistance. Don't delay emergency care during interpretation.
A conscious, competent patient retains the right to make medical decisions.
The power of attorney is only authorized when the patient is no longer capable.
DNR does not mean Do Not Treat it means Do Not Resuscitate (Still provide comfort care like oxygen and pain relief)