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Chapter 4 Medical, Legal, and Ethical Issues

National EMS Education Standard Competencies:

Preparatory Integrates comprehensive knowledge of the EMS system, safety/well-being of the paramedic, and medical/legal and ethical issues, which is intended to improve the health of EMS personnel, patients, and the community. National EMS Education Standard Competencies

National EMS Education Standard Competencies:

Medical/Legal and Ethics Consent/refusal of care Confidentiality Advance directives Tort and criminal actions Evidence preservation Statutory responsibilities National EMS Education Standard Competencies

National EMS Education Standard Competencies:

Medical/Legal and Ethics Mandatory reporting Health care regulation Patient rights/advocacy End-of-life issues Ethical principles/moral obligations Ethical tests and decision making National EMS Education Standard Competencies

Introduction:

Introduction Ethics Personal or societal principles that determine what is right and wrong Laws Enforceable sanctions for violations Obligations for paramedics © Brand X Pictures/ Creatas /Getty.

Introduction:

Introduction Paramedics work within several types of laws. Both federal and state You must understand the laws and ethics related to emergency care. Failure to perform your job can result in civil/criminal liability.

Introduction:

Introduction Ethics Deals with the study of the distinction between right and wrong This text is only a framework. Laws and obligations vary among states.

Medical Ethics:

Medical Ethics There are two types. Personal Professional In cases where they conflict, you must put your personal ethics aside. © Jones & Bartlett Learning. Courtesy of MIEMSS.

Medical Ethics:

Medical Ethics Medical ethics are related to the practice and delivery of medical care. Your understanding of medical ethics must be consistent with the codes of your profession. © Jones & Bartlett Learning. Courtesy of MIEMSS.

Medical Ethics:

Medical Ethics The Declaration of Geneva Drafted by the World Medical Association in 1948 Taken by medical students after completion of their studies Code of Ethics for EMS Practitioners Issued by the National Association of Emergency Medical Technicians in 1978 Still in use Pledge to a number of ethical codes

Medical Ethics:

Medical Ethics Your state, service, or company may have its own codes, policies, and rules. The ICARE Program was developed by EMS students and educators. Incorporates many of the finest qualities of EMS professionals All codes stem from concern for patients.

Medical Ethics:

Medical Ethics Apply three basic ethical concepts when making a decision: Do no harm. Act in good faith. Act in the patient ’ s best interest.

Medical Ethics:

Medical Ethics Paramedics must be accountable for their actions at all times. Choose a mentor. Professional ethics are also important. Always be respectful of patients. © Jones & Bartlett Learning. Courtesy of MIEMSS.

Medical Ethics:

Medical Ethics The ethics of your profession require: A total commitment to acting in the best interest of your patient That you otherwise conduct yourself in a professional and ethical manner at all times That you report misbehavior and medical errors

Medical Ethics:

Medical Ethics The most successful and fulfilled paramedics: Are patient advocates Engage in training and professional development Put the good of the team first You are responsible for the future of EMS.

Ethics and EMS Research:

Ethics and EMS Research EMS practices have largely evolved from g rassroots efforts. Properly randomized, controlled studies are uncommon, but are emerging. Remember, do no harm. Seek further education.

Ethics and EMS Research:

Ethics and EMS Research EMS care still relies on anecdotal experience. Some procedures prove not to be helpful. Conducting studies on patients without informed consent is an ethical dilemma. How are researchers handling ethical debates?

The Legal System in the United States:

The Legal System in the United States Federal and state government make, administer, and interpret laws affecting paramedics. Three branches of government © Jones & Bartlett Learning.

Types of Law:

Types of Law Two types of law govern paramedics in court: Civil Patient can sue for perceived injury Criminal State can prosecute for breaking a statute Courtesy of Oregon State Police.

Types of Law:

Types of Law Civil law addresses responsibility. Concerned with establishing liability Civil lawsuit is a legal action instituted by a private person or entity Most lawsuits result from vehicle crashes. Criminal prosecution can also result from a civil act. Action taken by government against someone prosecutors believe violated a law

Types of Law:

Types of Law Criminal charges most likely: Assault Battery False imprisonment Defamation, libel or slander © Dan Myers.

The Legal Process:

The Legal Process Begins when a complaint is filed Process may take several years Discovery period Motions Settlement process or trial © Photodisc /Getty.

The Paramedic and the Medical Director:

The Paramedic and the Medical Director The relationship is complex. Paramedic must answer to: Medical director Licensing agency Employer Despite overlap, distinctions are important.

The Paramedic and the Medical Director:

The Paramedic and the Medical Director Legislation may require a medical director. Supervises paramedic Paramedic is not the medical director ’ s agent The medical director may issue remedial requirements. Not responsible for disciplinary actions

The Paramedic and the Medical Director:

The Paramedic and the Medical Director Many paramedic activities require orders from a physician. Online or off-line If conflicts arise, online medical control should resolve them. Borrowed servant doctrine protects your institution. Don’t follow orders that fall outside your scope of practice.

EMS-Enabling Legislation:

EMS-Enabling Legislation Defines EMS structure Designates responsibilities to government agencies Provides framework for practice Know EMS legislation in your state.

Administrative Regulations:

Administrative Regulations Set by bureaucracies at state and federal levels Affect and define rules for practice Allow an administrative agency may take action against a paramedic ’ s license

Licensure and Certification:

Licensure and Certification Terms often confused Certification Certain levels of credentials Criteria met for minimum competency Licensure Privilege granted by government authority Credentialing possibly adopted

Discipline and Due Process:

Discipline and Due Process Licensing action may be taken if an infraction occurs. Paramedic has a right to due process. Notice Opportunity to be heard

Medical Practice Act:

Medical Practice Act Defines minimum qualifications of health service providers Defines skills practitioners can use Establishes means of licensure/certification May also include relicensure requirements

Scope of Practice:

Scope of Practice Care paramedic may perform according to the state under its license or certification The medical director might not permit paramedic to perform all skills/give all medications. Practicing outside scope of practice: negligence or a criminal offense

Health Insurance Portability and Accountability Act:

Health Insurance P ortability and Accountability A ct HIPAA Stringent privacy requirements Provides for criminal sanctions and civil penalties © Jones & Bartlett Learning. Courtesy of MIEMSS.

Health Insurance Portability and Accountability Act:

Health Insurance Portability and Accountability Act Information can be disclosed: For treatment For payment When authorized Privacy officer required Ensures PHI is not released illegally © Jones & Bartlett Learning. Courtesy of MIEMSS.

Health Insurance Portability and Accountability Act:

Health Insurance Portability and Accountability Act HIPAA requires that patients are provided a copy of your service’s privacy policies. Some states have patient confidentiality laws. Confidentiality is part of the Code of Ethics for Emergency Medical Technicians.

Health Insurance Portability and Accountability Act:

Health Insurance Portability and Accountability Act Medical information can be released without patient’s authorization: Legally mandated reporting Authorized data collection Research by public health agencies Authorized requests by law enforcement Pursuant to a valid subpoena For a medical need

Health Insurance Portability and Accountability Act:

Health Insurance Portability and Accountability Act HIPAA implications for electronic communication Some agencies prohibit camera-enabled phones while on duty. Ensure everyone understands information should not be posted on social media. Ensure no patient identifiers are present if scene is captured in photographs or videos.

Emergency Medical Treatment and Active Labor Act:

Emergency Medical Treatment and Active Labor Act EMTALA Established to combat “patient dumping” Decisions not based on finances Know local transport selection protocols Guarantees medical screening exam and treatment Regulates patient transfers © Gary Kazanjian/AP Photo.

Emergency Vehicle Laws:

Emergency Vehicle Laws Most states have specific statutes. Define emergency vehicle Dictate what traffic should do Emergency vehicles must be operated safely. Most states have a higher standard for EMS. If a crash occurs, EMS is usually at fault.

Transportation:

Transportation Patients should be transported to hospital of their choice when possible/reasonable. Most EMS have protocols that direct transport. Paramedics can be liable if patient: Is transported to an unequipped facility Is not transported and later deteriorates

Crime Scene and Emergency Scene Responsibilities:

Crime Scene and Emergency Scene Responsibilities Use extreme caution. Do not move or touch anything unless absolutely necessary. Limit personnel who enter the scene. Patient may carry evidence in rape cases. Protect scene from contamination. When in doubt, attempt resuscitation.

Mandatory Reporting:

Mandatory Reporting Each state has its own requirements. Virtually every state has laws for reporting child and elder abuse. Many states have immunity provisions. Failure to report is a crime. Know reporting requirements in your state.

Coroner and Medical Examiner Cases:

Coroner and Medical Examiner Cases EMS systems have a list of procedures. Notify police in these situations: Homicide Suicide Violent or sudden, unexpected death Death of a prison inmate © Frances Roberts/Alamy.

Paramedic–Patient Relationships:

Paramedic–Patient Relationships Always do what is best for the patient. Decisions should be based on standards of good medical care. Not possible legal consequences

Consent and Refusal:

Consent and Refusal You must obtain consent before providing care. To provide consent, a patient must: Be of legal age Possess decision-making capacity Patients can refuse care.

Consent and Refusal:

Consent and Refusal Informed consent Must be obtained from every adult with decision-making capacity To obtain informed consent: Describe the problem and proposed treatment. Discuss risks and alternatives. Advise the patient of consequences of refusal.

Consent and Refusal:

Consent and Refusal Expressed consent Patient gives you permission to provide care Implied consent Consent that is assumed when an adult is unconscious or too ill/injured to verbally consent Involuntary consent an oxymoron Persons under arrest or in prison still have right to be involved in medical treatment decisions.

Decision-Making Capacity:

Decision-Making Capacity Refusals must be informed. Decision-making capacity is the ability of the patient to: Understand information. Process information. Make a choice.

Decision-Making Capacity:

Decision-Making Capacity If a conscious patient with decision-making capacity refuses treatment: Cannot be treated without a court order Consult with medical control. Use your people skills.

Decision-Making Capacity:

Decision-Making Capacity It may not be clear as to whether or not a patient has decision-making capacity. Many factors can affect decision-making capacity. Contact medical control if necessary. Consider calling for assistance or law enforcement.

Decision-Making Capacity:

Decision-Making Capacity Psychiatric emergencies present problems of consent. Police officers are generally the only persons with authority to restrain and transfer a patient against his or her will. The role of each agency should be clearly defined beforehand.

Decision-Making Capacity:

Decision-Making Capacity If patient refuses treatment: Do not close any doors. Inform the patient that if he changes his mind, you will help him. Maintain a courteous and sympathetic attitude. Urge the patient to seek further medical evaluation. Make sure someone will be with the patient after you leave. Never threaten the patient.

Decision-Making Capacity:

Decision-Making Capacity Documentation of patient refusals is critical. Litigation may arise. Document all findings of assessment and mental status. Report should be signed: By the patient By an impartial observer (police officer)

Minors:

Minors Obtain consent from a legal guardian. In loco parentis if guardian is unavailable Notify law enforcement and medical control if a parent refuses necessary treatment. State may assume custody

Minors:

Minors Emancipated minors Treated as legal adults because of qualifying circumstances Skill in obtaining consent Your expertise will build over time. © Jones & Bartlett Learning. Courtesy of MIEMSS.

Violent Patients and Restraints:

Violent Patients and Restraints You can only use force in response to a patient ’ s force against you. Do not enter an unsafe scene. Only restrain medical patients who are a danger to themselves or others. © Jones & Bartlett Learning.

Negligence and Protection Against Negligence Claims:

Negligence and Protection Against Negligence Claims You have no protection for gross negligence. Negligence occurs when: There was a legal duty to the patient. There was a breach of duty. The failure to act was the proximate cause of injury. Harm resulted.

Negligence and Protection Against Negligence Claims:

Negligence and Protection Against Negligence Claims Behaving according to established standards and procedures is the best protection. Consider insurance coverage. Foreseeability is one aspect of negligence. Injury or harm could have been predicted.

Negligence and Protection Against Negligence Claims:

Negligence and Protection Against Negligence Claims Negligence is typically divided into three categories: Malfeasance Misfeasance Nonfeasance

Elements of Negligence:

Elements of Negligence Duty This is prescribed by law. Do no further harm to patient. You are obligated to respond to calls while working. This typically does not apply while you are off duty. Make sure appropriate personnel respond.

Elements of Negligence:

Elements of Negligence Duty (cont ’ d) You must perform within a standard of care when providing assistance. You cannot abandon the patient once care begins. You must maintain licensure or certification and skills. EMS systems can be held to a legal duty.

Elements of Negligence:

Elements of Negligence Breach of duty Occurs if the paramedic failed to perform within the standard of care. What a reasonable paramedic would do in a similar situation Some states distinguish between ordinary and gross negligence. Re ipsa loquitur or negligence per se may apply.

Elements of Negligence:

Elements of Negligence Proximate cause Improper action or failure to act caused harm. Harm Usually physical injury May also include emotional distress, loss of income, loss of spousal consortium, etc.

Abandonment:

Abandonment Abandonment is termination of care without the patient ’ s consent. Implies continuing need for treatment Once you respond, you cannot leave until a provider with equal or higher training takes responsibility.

Abandonment:

Abandonment Complete a written report. Some situations may not require transport but are not considered abandonment. Medical director will provide protocols. Generally, encourage transport. Know your service ’ s protocols.

Patient Autonomy:

Patient Autonomy Patients have the right to direct their own care This applies in almost every case. Respect and honor patient ’ s rights. Regardless of perceptions of others Even if patient ’ s death is result

Patient Autonomy:

Patient Autonomy Resolve ethical conflicts through communication. If you disagree with a physician, discuss it. Always act as a patient advocate.

Advance Directives:

Advance Directives Express what medical care (if any) the patient wants if he or she can no longer articulate personal wishes Differs from state to state Laws are often very strict. Know and follow state laws.

Living Will and Health Care Power of Attorney:

Living Will and Health Care Power of Attorney Types of advance directives Related to end-of-life medical care Sometimes called durable powers of attorney Various types of powers of attorney Not all authorize health care

Living Will and Health Care Power of Attorney:

Living Will and Health Care Power of Attorney Review the power of attorney carefully. Contact medical control when in doubt. Living wills generally require a precondition. A living will often contains a health care power of attorney. Consult medical control if it does not.

Living Will and Health Care Power of Attorney:

Living Will and Health Care Power of Attorney Surrogate decision maker Has no authority until the patient becomes incapable. Defer to patient whenever possible. © Jones & Bartlett Learning. Photographed by Kimberly Potvin .

DNR Orders:

DNR Orders Describes which life-sustaining procedures, if any, should be performed Laws differ among states. An order may include a physician order or medical jewelry. Courtesy of the MedicAlert Foundation ® . © 2006, All Rights Reserved. MedicAlert ® is a federally registered trademark and service mark. © Jones & Bartlett Learning.

DNR Orders:

DNR Orders Generally, DNRs must: Clearly state medical condition Have patient/guardian signature Have signature of one or more physicians You must still provide supportive measures if a patient is not in cardiac arrest.

Withholding or Withdrawing Resuscitation:

Withholding or Withdrawing Resuscitation A decision relies on common sense and reasonable judgment. Consider: Time to reach definitive care Likelihood of survival Rare survival cases should not guide your decisions. © Joe Pugliese /Los Angeles Times/Getty.

Withholding or Withdrawing Resuscitation:

Withholding or Withdrawing Resuscitation State laws vary. State laws continue to govern your practice with deceased patients. If resuscitation has begun, cessation may be appropriate in cases of: Blunt trauma arrest Prolonged rescue or response time Lengthy medical resuscitation efforts

Withholding or Withdrawing Resuscitation:

Withholding or Withdrawing Resuscitation Halting resuscitation is especially difficult with pediatric patients. Seek training, review literature, and have open discussions regarding resuscitation. Understand consequences of interventions. When in doubt, contact medical control.

End-of-Life Decisions:

End-of-Life Decisions You will often deal with patients at the very end of their lives. Treat patients with respect and empathy. Never question their reasoning. Providing information and support is part of your job.

End-of-Life Decisions:

End-of-Life Decisions Avoid imposing your own moral code. Respect the patient ’ s wishes, even if you disagree. You may encounter confusing scenarios. Resuscitate until paperwork is confirmed. Avoid hostile encounters with family members who disagree with the patient ’ s wishes.

End-of-Life Decisions:

End-of-Life Decisions Medical orders for life-sustaining treatment (MOLST) Similar to DNR, but more expansive May apply with impending pulmonary failure Guide use of CPR, intubation, feeding tubes, antibiotics, palliative care

End-of-Life Decisions:

End-of-Life Decisions Organ donation Keeping a patient alive for an organ donation is a major ethical issue. Understand state laws. Attend workshops. EMS plays a vital role in securing transplants. © Jones & Bartlett Learning.

Defenses to Litigation:

Defenses to Litigation Your first defense is an open, informative, trust-based relationship with patients. When this is not possible, several defenses may be used, including: Statute of limitations Contributory negligence

Good Samaritan Legislation:

Good Samaritan Legislation Provides immunity from liability Passed to encourage public to help Some protection for EMS personnel Does not apply while on duty Legal duty applies Must do all you can, within your knowledge

Governmental and Qualified Immunity:

Governmental and Qualified Immunity Governmental immunity Sovereign immunity Limits Types of lawsuits that can be filed Time frames Amount of money that can be recovered

Governmental and Qualified Immunity:

Governmental and Qualified Immunity Qualified immunity Common complaints: Improper restraint Excessive force Deviation from standard of care Only liable when paramedic violated a clearly established law

Employment Law and the Paramedic:

Employment Law and the Paramedic Laws affect your relationship with your employer. Involvement in legal issue with employer is more likely than being sued Employer–employee relationship involves complex state and federal laws. Have basic understanding

Americans With Disabilities Act (ADA):

Americans With Disabilities Act (ADA) Protects qualified persons with disabilities from employment discrimination All aspects of employment (hiring, salary, etc.) For ADA protection, a person must: Have a disability that limits life activities Possess the basic qualifications and be able to perform the essential job functions

Americans With Disabilities Act (ADA):

Americans With Disabilities Act (ADA) Employers cannot inquire about disabilities or require a medical exam until after the job offer is made. Reasonable accommodations must be provided. Employers are not required to give preference to disabled employees.

Title VII of the Civil Rights Act:

Title VII of the Civil Rights Act Prohibits discrimination based on race, color, religion, gender, national origin Also prohibits sexual harassment Applies to all aspects of employment Generally, a pattern over time, not single incident

Sexual Harassment:

Sexual Harassment One of the most common Title VII claims Two types: Quid pro quo Hostile environment Can occur between any combination of sexes, sexual orientations, or gender identities No precise definition of harassment

Sexual Harassment:

Sexual Harassment Typically includes: Sexual comments Display of offensive material Unwelcome advances, touching Inappropriate personal inquiries Employers obligated to prevent harassment Must investigate all claims promptly Must provide training

Additional Federal Laws Dealing With Discrimination:

Additional Federal Laws Dealing With Discrimination Pregnancy Discrimination Act Equal Pay Act of 1963 Men and women who perform equal work in the same workplace must receive equal pay. Age Discrimination in Employment Act of 1967

State Laws:

State Laws Deal with discrimination in the workplace Compared to federal law: Address same issues Sometimes provide more rights Do not usually require 15 or more employees Familiarity with laws in your state

Family Medical Leave Act (FMLA):

Family Medical Leave Act (FMLA) Up to 12 weeks unpaid leave per year For eligible employees Under certain circumstances States’ own versions May provide more rights

Occupational Safety and Health Administration (OSHA):

Occupational Safety and Health Administration (OSHA) OSHA regulates safety in the workplace. States may enforce tighter regulations. OSHA covers all employers. Additional responsibilities in health care Standards are often changing Do all you can to avoid injuries.

Ryan White Act:

Ryan White Act Provides safeguards and protections for health care workers exposed or potentially exposed to certain designated diseases. Notify your infection control officer if you believe you have been exposed.

National Labor Relations Act (Wagner Act):

National Labor Relations Act (Wagner Act) Many EMS services are unionized. Establishes: Rights of unions and union workers Regulates unfair labor practices by employers Become familiar with your rights and the union laws in your state.

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