medicolegal and ethical issues

Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved.

Medicolegal and Ethical Medicolegal and Ethical IssuesIssues

Chapter 3Chapter 3


Case HistoryCase History

You respond to a nursing home to find a 90-year-old You respond to a nursing home to find a 90-year-old patient who has a “do not resuscitate order” (DNR). patient who has a “do not resuscitate order” (DNR). While you are transporting the patient to the hospital, While you are transporting the patient to the hospital, he becomes unconscious and has no pulse.he becomes unconscious and has no pulse.


Ethical ResponsibilitiesEthical Responsibilities

Practice the golden rule when treating patients: Practice the golden rule when treating patients: “Do unto others as you would have them do unto you.” “Do unto others as you would have them do unto you.”


Ethical ResponsibilitiesEthical Responsibilities

Making the physical/emotional needs of the patient a priorityMaking the physical/emotional needs of the patient a priority

Maintaining skills to the point of masteryMaintaining skills to the point of mastery Continuing educationContinuing education Call reviewCall review Follow-up with physician about patients treated Follow-up with physician about patients treated

Critically reviewing performanceCritically reviewing performance

Honesty in reportingHonesty in reporting


Case HistoryCase History

Your supervisor advises you that you have Your supervisor advises you that you have been subpoenaed to appear in court regarding been subpoenaed to appear in court regarding a patient you treated 2 years ago.a patient you treated 2 years ago.

What would be your greatest areas of What would be your greatest areas of concern?concern?


Key Concerns: Did I…Key Concerns: Did I…

… … maintain patient confidentiality?maintain patient confidentiality? … … properly report a special situation?properly report a special situation? … … treat the patient according to the standard of treat the patient according to the standard of

care? care? … … have my equipment available and in working have my equipment available and in working

order? order? … … effectively document assessment and care?effectively document assessment and care? … … properly achieve consent for care?properly achieve consent for care? … … abandon care prematurely?abandon care prematurely?


ConfidentialityConfidentiality

Confidential informationConfidential information

Written release required to release informationWritten release required to release information

Situations when no release requiredSituations when no release required Transfer to health care providersTransfer to health care providers Reporting of incidents mandated by state lawReporting of incidents mandated by state law Third-party payer billing formsThird-party payer billing forms Legal subpoenaLegal subpoena


Special Reporting SituationsSpecial Reporting Situations Vary from state to stateVary from state to state AbuseAbuse Crime Crime Wounds from guns and knivesWounds from guns and knives Animal bitesAnimal bites DeathDeath Infectious disease exposure Infectious disease exposure Patient restraint lawsPatient restraint laws Mentally incompetent (e.g., intoxicated Mentally incompetent (e.g., intoxicated

with injuries)with injuries)


Scope of PracticeScope of Practice

Legal duties to the patient, medical director, and publicLegal duties to the patient, medical director, and public

Defined by state legislationDefined by state legislation

Enhanced by medical directionEnhanced by medical direction Protocols and standing ordersProtocols and standing orders

National Standard CurriculumNational Standard Curriculum

Legal right to function as an EMT-BasicLegal right to function as an EMT-Basic May be contingent on medical directionMay be contingent on medical direction


Standard of CareStandard of Care Knowledge, laws, standards, policies, and guidelines that provide the Knowledge, laws, standards, policies, and guidelines that provide the

basis of practicebasis of practice ExamplesExamples

• DOT National Standard Curriculum for the EMT-BasicDOT National Standard Curriculum for the EMT-Basic• American Heart Association CPR guidelinesAmerican Heart Association CPR guidelines• ProtocolsProtocols• State regulationsState regulations

State laws may also define testing standards.State laws may also define testing standards.

Expert witnesses may help define standard of care via deposition or Expert witnesses may help define standard of care via deposition or testimony.testimony.


EquipmentEquipment Legally, the EMT-Basic is Legally, the EMT-Basic is

expected to expected to provide reasonable careprovide reasonable care carry the appropriate equipment in carry the appropriate equipment in

working orderworking order

Equipment failure may provide a Equipment failure may provide a basis for a lawsuitbasis for a lawsuit

Equipment failure should be Equipment failure should be carefully documented in the carefully documented in the patient recordpatient record


NegligenceNegligence

Deviation from the accepted Deviation from the accepted standard of care resulting in standard of care resulting in injury to the patient injury to the patient

Ingredients of medical Ingredients of medical malpracticemalpractice Duty to actDuty to act Breach of dutyBreach of duty Injury/damagesInjury/damages Causal connection to EMTCausal connection to EMT


Duty to ActDuty to Act ImpliedImplied

Patient calls and dispatcher confirms responsePatient calls and dispatcher confirms response Patient treatment is initiated.Patient treatment is initiated.

FormalFormal EMS agency has a written contract with a municipalityEMS agency has a written contract with a municipality

Legal duty to act may not exist.Legal duty to act may not exist. Moral/ethical considerations Moral/ethical considerations

may existmay exist


ImmunitiesImmunities

Good Samaritan LawsGood Samaritan Laws Designed to protect Designed to protect

volunteersvolunteers• MedicalMedical• Lay rescuersLay rescuers

Protection of Protection of government workers government workers (e.g., military)(e.g., military)


ConsentConsent

ExpressedExpressed

ImpliedImplied

ChildrenChildren

Mentally incompetent Mentally incompetent patientspatients


Assault/BatteryAssault/Battery

Unlawfully Unlawfully touching a person touching a person without consentwithout consent

Providing care Providing care without consentwithout consent


RefusalsRefusals

Patient has the right to refuse treatmentPatient has the right to refuse treatment Patient may withdraw from treatment at any timePatient may withdraw from treatment at any time Refusals must be made by mentally competent adultsRefusals must be made by mentally competent adults Patient must be informed of risks and consequences of Patient must be informed of risks and consequences of

refusalrefusal When in doubtWhen in doubt

Contact medical direction.Contact medical direction. Err in favor of providing care.Err in favor of providing care.


Documentation of Refusal –Documentation of Refusal –ProcessProcess

Try to persuade the patient to allow treatment.Try to persuade the patient to allow treatment. Ensure that the patient is competent to make Ensure that the patient is competent to make

decision.decision. Inform the patient of risks and consequences.Inform the patient of risks and consequences. Consult medical direction (per local protocol).Consult medical direction (per local protocol). Consider assistance from law enforcement.Consider assistance from law enforcement. Document any findings and care given.Document any findings and care given. Patient should sign a refusal form.Patient should sign a refusal form. Never make an independent decision not to Never make an independent decision not to

transport.transport.


AbandonmentAbandonmentDefinition:Definition:

Termination of patient care without ensuring the Termination of patient care without ensuring the continuation of care at the same level or highercontinuation of care at the same level or higher


Intoxicated, Irrational, and Intoxicated, Irrational, and Emotionally Disturbed PatientsEmotionally Disturbed Patients

Emotionally disturbed patients represent an area of high Emotionally disturbed patients represent an area of high legal risk.legal risk.

Always exercise caution.Always exercise caution.

When forcible removal is necessary:When forcible removal is necessary: Care should be taken to not harm the patientCare should be taken to not harm the patient Soft restraints should be usedSoft restraints should be used Precise documentation is essentialPrecise documentation is essential


Advanced DirectivesAdvanced DirectivesDNR OrdersDNR Orders

Patient has the right to refuse Patient has the right to refuse resuscitative effortsresuscitative efforts

Generally, a written physician Generally, a written physician order is required.order is required.

Follow state and local Follow state and local legislation/protocols.legislation/protocols.

When in doubt, begin When in doubt, begin resuscitation efforts.resuscitation efforts.


Donor and Organ HarvestingDonor and Organ Harvesting

Individual may decide in advance to donate organs.Individual may decide in advance to donate organs. May be indicated on a driver’s license or donor cardMay be indicated on a driver’s license or donor card

Treat the same as any other patient.Treat the same as any other patient.

If you become aware of a patient’s organ donor status, If you become aware of a patient’s organ donor status, you should communicate this to the hospital or medical you should communicate this to the hospital or medical direction.direction.


Crime Scene/Evidence Crime Scene/Evidence PreservationPreservation

Dispatch should notify police.Dispatch should notify police.

Responsibility of EMT:Responsibility of EMT: Emergency care is priorityEmergency care is priority Do not disturb scene unless Do not disturb scene unless

emergency care requires itemergency care requires it Observe and document anything Observe and document anything

unusual at the sceneunusual at the scene

If possible, do not cut clothing from If possible, do not cut clothing from patientpatient


Risk ManagementRisk Management

Act according to the Act according to the standard of care.standard of care.

Act in the best interest Act in the best interest of the patient.of the patient.

Document your actions.Document your actions.

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