legal and ethical issues legal and ethical issues chapter 4

Legal and Ethical IssuesLegal and Ethical Issues

Chapter 4Chapter 4

Topic OverviewTopic Overview

Standard of care / Scope of practiceStandard of care / Scope of practice ConsentConsent

Informed (Expressed)Informed (Expressed) ImpliedImplied Children and mentally Incompetent Children and mentally Incompetent

AdultsAdults Refusal of CareRefusal of Care Advanced DirectivesAdvanced Directives

Do Not Resuscitate (DNR) orders Do Not Resuscitate (DNR) orders Living wills.Living wills.

ObjectivesObjectives

NegligenceNegligence DutyDuty

Legal vs. moralLegal vs. moral Breach of DutyBreach of Duty

AbandonmentAbandonment Battery Battery

CausationCausation DamagesDamages

Good Samaritan LawsGood Samaritan Laws ConfidentialityConfidentiality Crime scene preservationCrime scene preservation DocumentationDocumentation

Legal and Ethical Legal and Ethical ConsiderationsConsiderations

Legal DutiesLegal Duties All states have established guidelines to All states have established guidelines to

allow emergency care to be given allow emergency care to be given without worry of being sued.without worry of being sued.

Laws require a certain “Standard of Care”Laws require a certain “Standard of Care” Standard of Care Standard of Care

Care expected based on the provider’s Care expected based on the provider’s training and experience, taking into account training and experience, taking into account the conditions under which the care is the conditions under which the care is rendered.rendered.


Based on laws, administrative orders and Based on laws, administrative orders and guidelines published by the EMS system, guidelines published by the EMS system, organizations and societies.organizations and societies.

First Responder guidelines established byFirst Responder guidelines established by USDOTUSDOT StateState Institutional (PCC and CCE)Institutional (PCC and CCE)


Ethical ResponsibilitiesEthical Responsibilities Primary ConsiderationPrimary Consideration

Make the physical and emotional needs of the patient a Make the physical and emotional needs of the patient a prioritypriority

Additional ResponsibilitiesAdditional Responsibilities Maintaining skills and knowledgeMaintaining skills and knowledge

Includes practicing until you have obtained confidence and Includes practicing until you have obtained confidence and mastery of the skillsmastery of the skills

Continuing education and refresher programsContinuing education and refresher programs Review your performance and assess the techniques you Review your performance and assess the techniques you

useuse Evaluate yourselfEvaluate yourself Be honest in reporting care providedBe honest in reporting care provided


ConsentConsent ConsentConsent

Patient says or acknowledges that Patient says or acknowledges that you can treat themyou can treat them

Expressed Consent Expressed Consent Consent given by a rational adult after Consent given by a rational adult after

being informed of the provider’s training being informed of the provider’s training and what care procedures are to be done. and what care procedures are to be done. Risks and options to care.Risks and options to care.


Implied ConsentImplied Consent An unconscious patient is assumed to want help.An unconscious patient is assumed to want help.

A legal position that assumes an unconscious or badly A legal position that assumes an unconscious or badly injured adult patient would consent to receiving injured adult patient would consent to receiving emergency care.emergency care.

May apply to other type of patients as wellMay apply to other type of patients as well Mentally illMentally ill

Children and Mentally Incompetent AdultsChildren and Mentally Incompetent Adults Parental ConsentParental Consent Serious Injury/Illness in the absence of a parentSerious Injury/Illness in the absence of a parent

A form of implied consentA form of implied consent


CompetenceCompetence The patient’s ability to understand your The patient’s ability to understand your

questions.questions. The patient’s ability to understand the The patient’s ability to understand the

implications of decisions made.implications of decisions made. Not competent when:Not competent when:

intoxicatedintoxicated drug ingestiondrug ingestion serious injuryserious injury mental incompetencemental incompetence

Legal and Ethical IssuesLegal and Ethical Issues To determine competenceTo determine competence

Ask QuestionsAsk Questions PPTEPPTE WWWWHWWWWH

Remember answering questions does not always Remember answering questions does not always establish competence - Suicidalestablish competence - Suicidal


Refusal of CareRefusal of Care When conscious and competent patients can When conscious and competent patients can

refuse your carerefuse your care Reasons may be based onReasons may be based on

religious groundsreligious grounds lack of trustlack of trust personal reasonspersonal reasons

You CAN NOT force care on these patientsYou CAN NOT force care on these patients You CAN NOT legally restrain them until EMS You CAN NOT legally restrain them until EMS

arrivesarrives


Only Course of ActionOnly Course of Action Try to gain their confidence through conversationTry to gain their confidence through conversation When your services are refused:When your services are refused:

Do Not argueDo Not argue Do Not question their reasons (if based on religious Do Not question their reasons (if based on religious

views)views) Do Not touchDo Not touch Stay Calm and ProfessionalStay Calm and Professional Make sure EMS has been activatedMake sure EMS has been activated Talk to the patientTalk to the patient If possible have a neutral witness to your offer to helpIf possible have a neutral witness to your offer to help


If a patient is not competent they cannot refuse If a patient is not competent they cannot refuse medical care or give consentmedical care or give consent

Often times this is where law enforcement becomes Often times this is where law enforcement becomes involved i.e...mental warrantinvolved i.e...mental warrant

A parent or guardian can refuse to let you care for a A parent or guardian can refuse to let you care for a childchild

Follow the previously discussed steps.Follow the previously discussed steps. IF an adult takes a child from the scene before IF an adult takes a child from the scene before

EMS arrives, you must report the incident to EMS EMS arrives, you must report the incident to EMS or the policeor the police

Conscious patient refuses care then becomes Conscious patient refuses care then becomes unconscious, implied consent usually takes over unconscious, implied consent usually takes over and care beginsand care begins


Advance DirectivesAdvance Directives DNR (Do Not Resuscitate) OrdersDNR (Do Not Resuscitate) Orders

Legal documentLegal document Signed by physician and patientSigned by physician and patient Terminal illness & does not wish to prolong life Terminal illness & does not wish to prolong life

through resuscitative effortsthrough resuscitative efforts Texas has a state wide form that must be usedTexas has a state wide form that must be used The Original DNR form or a copy of the form The Original DNR form or a copy of the form

are to be accepted (NEW)are to be accepted (NEW) Approved ID bracelet with patient information Approved ID bracelet with patient information

engravedengraved


Living WillsLiving Wills Document signed by patient regarding use Document signed by patient regarding use

of long-term life support and comfort of long-term life support and comfort measures such as respirators, intravenous measures such as respirators, intravenous feedings, pain medications.feedings, pain medications.


NegligenceNegligence Basis for most lawsuits involving Basis for most lawsuits involving

prehospital care is negligenceprehospital care is negligence You could be sued IF:You could be sued IF:

You had a Duty to Provide care or you You had a Duty to Provide care or you assume the responsibility to provide careassume the responsibility to provide care

Care for the patient was not provided to the Care for the patient was not provided to the “standard of care”“standard of care”

Patient was injured in some way as a result Patient was injured in some way as a result of this improper careof this improper care


Duty to ActDuty to Act While on duty a first responder has a While on duty a first responder has a

obligation to respond to an emergency and obligation to respond to an emergency and provide care at the sceneprovide care at the scene

Your duty to act may involve your officeYour duty to act may involve your office If you volunteer for an organization, you have a If you volunteer for an organization, you have a

duty to act within the respond area of that duty to act within the respond area of that organization organization

As a Doctor of Chiropractic?????As a Doctor of Chiropractic?????

Breach of DutyBreach of Duty Substandard care or care given beyond your Substandard care or care given beyond your

level of traininglevel of training


Assault / BatteryAssault / Battery Not a universal definitionNot a universal definition

Unlawful touching of a victim without their Unlawful touching of a victim without their consentconsent

Providing care when a competent patient Providing care when a competent patient refuses carerefuses care

Legal ConsiderationsLegal Considerations

In Texas an assault is comparable In Texas an assault is comparable crime under the Texas Penal Codes.crime under the Texas Penal Codes.

CHAPTER 22. ASSAULTIVE OFFENSESCHAPTER 22. ASSAULTIVE OFFENSES Sec. 22.01. Assault.Sec. 22.01. Assault.

(a) A person commits an offense if the person:(a) A person commits an offense if the person: (b) intentionally or knowingly causes physical (b) intentionally or knowingly causes physical

contact with another when the person knows or contact with another when the person knows or should reasonably believe that the other will should reasonably believe that the other will regard the contact as offensive or provocative.regard the contact as offensive or provocative.

(c) An offense under Subsection (a)(2) or (3) is a (c) An offense under Subsection (a)(2) or (3) is a Class C misdemeanor, except that an offense Class C misdemeanor, except that an offense under Subsection (a)(3) is a Class A misdemeanor under Subsection (a)(3) is a Class A misdemeanor if the offense was committed against an elderly if the offense was committed against an elderly individual or disabled individual, as those terms individual or disabled individual, as those terms are defined by Section 22.04.are defined by Section 22.04.


CauseCause If duty and breach of duty are established, If duty and breach of duty are established,

negligence may be proven if the action or negligence may be proven if the action or lack of action caused injury (damage) in lack of action caused injury (damage) in some form due directly to your actions.some form due directly to your actions.

DamageDamage Physical damagePhysical damage

Moving a patient before a fractured leg is Moving a patient before a fractured leg is splinted.splinted.


Emotional or PsychologicalEmotional or Psychological Inappropriate care does not always involve a Inappropriate care does not always involve a

physical skill, it could be you tell someone they physical skill, it could be you tell someone they don’t need emergency care when they do so EMS don’t need emergency care when they do so EMS is delayed and the delay caused complicationsis delayed and the delay caused complications

Good Samaritan LawsGood Samaritan Laws Grant immunity from civil liability if:Grant immunity from civil liability if:

you acted in good faithyou acted in good faith you provided care to the best of your abilityyou provided care to the best of your ability


AbandonmentAbandonment Once you stop to help you have legally Once you stop to help you have legally

begun carebegun care Once you start you have assumed a duty Once you start you have assumed a duty

to continue untilto continue until patient is turned over to more advanced patient is turned over to more advanced

medical personnel (EMS)medical personnel (EMS) You have abandoned the patient if:You have abandoned the patient if:

you leave before EMS or a person with you leave before EMS or a person with higher training arrives and takes overhigher training arrives and takes over

includes the failure to turn over patient includes the failure to turn over patient information during the transfer to more information during the transfer to more highly trained personnelhighly trained personnel


Confidentiality Confidentiality Confidential InformationConfidential Information

history, gained through interviewhistory, gained through interview assessment findingsassessment findings emergency care renderedemergency care rendered

Releasing Confidential InformationReleasing Confidential Information Required written release from the patientRequired written release from the patient Not required when EMS personnel need information Not required when EMS personnel need information

to continue careto continue care SubpoenaSubpoena


Reportable EventsReportable Events Include:Include:

exposure to blood and OPIMexposure to blood and OPIM certain infectious diseasescertain infectious diseases vehicle accidentsvehicle accidents drug-related injuriesdrug-related injuries crimes resulting in knife or gunshot woundscrimes resulting in knife or gunshot wounds child and elder abusechild and elder abuse domestic violencedomestic violence raperape


Special SituationsSpecial Situations Organ DonorsOrgan Donors

Emergency care must not differEmergency care must not differ All emergency care measures must be taken All emergency care measures must be taken

including CPRincluding CPR Medical Identification DevicesMedical Identification Devices

Look for a necklace, bracelet, ankle bracelet, Look for a necklace, bracelet, ankle bracelet, cardcard


Crime ScenesCrime Scenes Evidence PreservationEvidence Preservation

Don’t move anything Don’t move anything unless care absolutely requires itunless care absolutely requires it

Note position of the weapon if movedNote position of the weapon if moved Note the position of the patientNote the position of the patient Do not cut where the stab or gunshot wound cut Do not cut where the stab or gunshot wound cut

the clothingthe clothing

Scene should not be entered until it is Scene should not be entered until it is secure.secure.

Legal ConsiderationsLegal Considerations

DocumentationDocumentation If you do not write it down, a court of law If you do not write it down, a court of law

would say it did not happen!would say it did not happen! If paperwork to is sloppy and unreadable, If paperwork to is sloppy and unreadable,

a court of law would say care was also a court of law would say care was also sloppysloppy

legal and ethical issues legal and ethical issues chapter 4

Documents

reporting care

emergency care

care procedures

certain standard of

ethical issues legal

cce slide

responder guidelines

providers training