Medical/Legal Aspects of Prehospital Care :Medical/Legal Aspects of Prehospital Care Department of EMS Professions Temple College


Topics to Discuss :Topics to Discuss Legal vs. Ethical vs. Moral Responsibilities Review of the Legal System Specific Laws Applicable to EMS Accountability & Malpractice Specific Paramedic-Patient Issues Operational Issues Documentation


Legal vs. Ethical vs. Moral Responsibilities :Legal vs. Ethical vs. Moral Responsibilities What are the differences? Legal Responsibilities Ethical Standards Morality


Legal vs. Ethical vs. Moral Responsibilities :Legal vs. Ethical vs. Moral Responsibilities Legal Responsibilities Established by the law-making bodies of government Ethical Standards Principles of conduct identified by members of a group or profession Morality Individual’s assessment of right and wrong


The Legal System :The Legal System Sources of Law Constitutional Common Legislative Administrative Legislative and Administrative are often the focus of EMS Providers


The Legal System :The Legal System Federal vs. State Court Categories of Law Criminal Law Civil Law Tort Law What are examples of how each of these may affect the paramedic?


The Legal System :The Legal System Terminology Plaintiff Defendant Discovery phase Deposition Interrogation Documentation Appeal


Laws Affecting EMS :Laws Affecting EMS Scope of Practice Texas Medical Direction Intervener physician Ability to Practice Certification or Licensure Authorization to Practice


Laws Affecting EMS :Laws Affecting EMS Motor Vehicle Laws Infectious Disease Exposure Assault against Public Safety Officer Obstruction of Duty Good Samaritan Law Ryan White CARE Act


Laws Affecting EMS :Laws Affecting EMS Mandatory Reporting Domestic violence Child & Elder abuse Criminal Acts GSW, Stabbing & Assault Animal Bites Communicable Diseases Out of hospital deaths Possession of Controlled Substances


Accountability & Malpractice Issues :Accountability & Malpractice Issues Standard of Care Negligence Civil Litigation Specifics Borrowed Servant Doctrine Patient Civil Rights Liability when off-duty


Accountability & Malpractice :Accountability & Malpractice Standard of Care The expected care, skill, & judgment under similar circumstances by a similarly trained, reasonable paramedic Negligence Deviation from accepted or expected standards of care expected to protect from unreasonable risk of harm What are the required components for proof of a negligence claim in EMS?


Accountability & Malpractice :Accountability & Malpractice Elements Required to prove Negligence Duty to Act Breach of duty Actual damage or harm Proximate cause


Accountability & Malpractice :Accountability & Malpractice Civil Cases Proof of guilt required by a “preponderance of evidence” “res ipsa loquitur” Burden of proof shifts to the defendant Simple vs. Gross Negligence


Defenses :Defenses Good Samaritan Law Government Immunity Statue of Limitations Contributory Negligence


Accountability & Malpractice :Accountability & Malpractice How do these affect the Paramedic’s Practice? Borrowed Servant Doctrine Patient Civil Rights Liability when Off-Duty


Specific Paramedic-Patient Issues :Specific Paramedic-Patient Issues Issues Surrounding Consent Refusals Restraint Abandonment Transfer of Patient Care Advance Directives & End of Life Decisions Out of Hospital Death Confidentiality & Privacy


Specific Paramedic-Patient Issues :Specific Paramedic-Patient Issues Issues Surrounding Consent Patient has legal & mental capacity Patient understands consequences Types of Consent Informed Expressed Implied Involuntary


Specific Paramedic-Patient Issues :Specific Paramedic-Patient Issues Issues Surrounding Consent Specific Consent Issues Minors Emancipated Minor Prisoners


Specific Paramedic-Patient Issues :Specific Paramedic-Patient Issues Refusals Consent for Transport vs. Treatment Withdrawing Consent Refusal of Service Has legal & mental capacity Is informed of risks & benefits Offer alternatives All of the above are well documented & witnessed


Specific Paramedic-Patient Issues :Specific Paramedic-Patient Issues Refusals Incompetent Persons Unable to understand the nature & consequences of his/her injury/illness Unable to make rational decisions regarding medical care due to physical or mental conditions Do not assume incompetence unless obvious


Specific Paramedic-Patient Issues :Specific Paramedic-Patient Issues Restraint Definitions Assault Battery False Imprisonment


Specific Paramedic-Patient Issues :Specific Paramedic-Patient Issues Restraint In Custody of Law Enforcement or Corrections Patient is not competent to refuse & requires care Patient is a danger to self or others (involve law enforcement) Does not provide authorization to harm!


Specific Paramedic-Patient Issues :Specific Paramedic-Patient Issues Restraint Involve Law Enforcement Early Have a plan of action Ensure safety of all Reasonable force Physical restraints Chemical restraints Document well


Specific Paramedic-Patient Issues :Specific Paramedic-Patient Issues Patient Abandonment Unilateral termination of the patient-provider relationship Still needed and desired Exceptions MCI Risks to well-being Can a paramedic turn over care of a patient to an EMT?


Specific Paramedic-Patient Issues :Specific Paramedic-Patient Issues Transfer of Patient Care Transfer of Care to other Providers Transfer of Care at the ED


Specific Paramedic-Patient Issues :Specific Paramedic-Patient Issues Advanced Directives & End of Life Decisions Definitions Advanced Directive Out of Hospital DNR DNR vs. DNAR Living Will Durable Power of Attorney for Health Care Patient Self-Determination Act


Specific Paramedic-Patient Issues :Specific Paramedic-Patient Issues Advanced Directives & End of Life Decisions Living Will Durable Power of Attorney for Health Care Texas Out of Hospital DNR Terminal Condition no longer required Identification Devices EMS requirements Revocation Can a Texas Paramedic honor an Advanced Directive (other than a DNR)?


Specific Paramedic-Patient Issues :Specific Paramedic-Patient Issues Advanced Directives & End of Life Decisions Patient does not surrender rights to receive medical care Comfort measures appropriate Provide Family support and guidance When in doubt, resuscitate & contact medical control Termination of efforts allowed


Specific Paramedic-Patient Issues :Specific Paramedic-Patient Issues Out of Hospital Death Initiation of care? Many counties and cities require: law enforcement response and/or Justice of the peace pronouncement Some jurisdictions use a medical examiner or coroner system Required medical control authorization Survivors may now be the patients


Specific Paramedic-Patient Issues :Specific Paramedic-Patient Issues Patient Confidentiality & Privacy “Medical information about a patient will not be shared with a third party without consent, statute, or court order” Not all information is protected In some states, QA/QI information is not discoverable


Specific Paramedic-Patient Issues :Specific Paramedic-Patient Issues Patient Confidentiality & Privacy Colleague & Station Talk Must not identify the patient Maintains confidentiality of specific medical info Scene or Patient Photographs EMS Radio Dispatch & Discussions “Need to Know” Basis


Specific Paramedic-Patient Issues :Specific Paramedic-Patient Issues Patient Confidentiality & Privacy You have treated & transported a 50-year-old local salesman who is originally diagnosed in the ED with PCP. At the station, you discuss this case including the name of the patient’s business. Since PCP is associated with HIV/AIDS, your coworker suspects this man is infected. Your coworker discusses this case with a friend (the patient’s employer) who then discusses this matter with your patient (his employee). (cont’d)


Specific Paramedic-Patient Issues :Specific Paramedic-Patient Issues Group Discussion: Patient Confidentiality & Privacy 1. What are the possible consequences for you? 2. What if the patient does not have HIV/AIDS?


Specific Paramedic-Patient Issues :Specific Paramedic-Patient Issues Patient Confidentiality & Privacy Defamation “Communication of false information knowing the information to be false or with reckless disregard of whether it is true or false” Slander Libel Protected Classes/Diseases


Operational Issues :Operational Issues Equipment failure Interaction with Law Enforcement Crime Scenes Preservation of Evidence Vehicle Operation Medical Control Instructor Liability Hospital Selection Dispatch Interfacility Transfers OSHA Risk Management


Operational Issues :Operational Issues Equipment Failure Product Liability Design flaw in ventilator Failure on part of owner/operator No backup battery for defibrillator


Operational Issues :Operational Issues Interaction with Law Enforcement Crime Scenes Request law enforcement Await law enforcement arrival if possible Minimize areas of travel and contact with scene Document any alterations to the scene created by EMS personnel Minimize personnel within scene if possible Document pertinent observations


Operational Issues :Operational Issues Interaction with Law Enforcement Evidence Preservation Avoid cutting through penetrations in the clothing Save everything – clothing of assault victim, items found on person, etc Prevent sexual assault victim from washing Follow sound chain of evidence procedures


Operational Issues :Operational Issues Vehicle Operation It is 3:00 am. While responding to a MVC, a driver fails to yield the right of way at an intersection. The driver’s traffic signal is green. You attempt to stop but are unable to do so. Witnesses state your emergency lights were on but do not recall hearing your siren. The driver is injured.(cont’d)


Operational Issues :Operational Issues Vehicle Operation What issues might the driver’s attorney consider? Were all of your emergency lights really operational? Are daily inspections performed? Why was the siren not working? Were poorly maintained brakes responsible for your inability to stop? What type of PM is performed on your ambulance? Did you exercise due regard for the safety of others?


Operational Issues :Operational Issues Medical Control Issues Failure to follow med contr direction Following obviously harmful direction Implementing therapies without prior authorization Following direction of an unauthorized person Med Contr directs EMS to an inappropriate hospital The paramedic exceeds the scope of his training or medical authorization


Operational Issues :Operational Issues Instructor Liability Student discrimination Sexual harassment Student injury during laboratory Patient claim re. Failure to properly train graduate or supervise student Instructors – Follow curriculum, document student attendance & competency


Operational Issues :Operational Issues Hospital Selection Paramedic & Medical Control decision Closest & Appropriate Facility Written policies or guidelines What is the closest & most appropriate facility? What does this mean?


Operational Issues :Operational Issues Dispatch Issues Untimely dispatch Failure to provide responding units with adequate directions (incorrect address) Dispatch of inadequate level of care Failure to provide pre-arrival instructions Inadequate recordkeeping


Operational Issues :Operational Issues Interfacility Transfer Issues Do you have the necessary equipment & training? Should any specialized providers accompany you? Do you have a patient report including history? Is the patient “stable”? What are the potential complications? Are there any specific physician orders? Does the patient have a DNR order? Has the patient been accepted (MOT)? Who are the transferring & accepting physicians?


Operational Issues :Operational Issues OSHA & Risk Management OSHA generally not applicable to government employees New Texas Sharp Injury Prevention Rules In many States, State OSHA Rules are applicable to nearly all “Each employee shall comply with occupational safety and health standards and all rules, regulations, and orders issued persuant to this Act which are applicable to his own actions and conduct”


Documentation :Documentation Patient Confidentiality Securing/Sharing/Requests for Information Protected Classes Quality & Effectiveness


Documentation :Documentation Patient Confidentiality Written report only intended for those with a need to know Personal identifiers may be removed for QA/QI uses Patient radio reports should not contain personal identifiers


Documentation :Documentation Securing/Sharing/Requests for Information Where are completed patient reports stored? Who received the report at the ED? Requests for copies should be routed through an accepted policy or an attorney Does the requestor have a need to know?


Documentation :Documentation Protected Classes In some states, patient information related to sexually transmitted diseases or other specific diseases has become protected as confidential Washington state Can not refer to HIV/AIDS or STD status in report without consent Then, only with a clear need to know


Documentation :Documentation Quality & Effectiveness Complete soon after the patient contact Be thorough and accurate Be honest, objective and factual Caution with abbreviations Maintain confidentiality Do not alter


Documentation :Documentation Quality & Effectiveness Does your report relay to future healthcare providers the information you obtained regarding this patient? Is the information clear and concise? Will the report help you recall this incident if necessary 3 years from now? Are you willing to sit in court with only this document?


Summary :Summary There are many legal issues surrounding the EMS environment The paramedic should attempt to keep up-to-date with local legal requirements Ignorance is not acceptable!


Suggested Reference :Suggested Reference Cohn, B. M. Azzara, A. J. Legal Aspects of Emergency Medical Services. W. B. Saunders Company. 1998