Medical/Legal Aspects of Prehospital Care
Department of EMS Professions Temple College
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
What are the differences?
Legal Responsibilities Ethical Standards Morality
The Legal System
Sources of Law
Constitutional Common Legislative Administrative
Legislative and Administrative are often the focus of EMS Providers
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
Terminology
Plaintiff Defendant Discovery phase
Deposition Interrogation Documentation
Appeal
Laws Affecting EMS
Scope of Practice
Texas Medical Direction Intervener physician
Ability to Practice
Certification or Licensure Authorization to Practice
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
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
Standard of Care Negligence Civil Litigation Specifics Borrowed Servant Doctrine Patient Civil Rights Liability when off-duty
Accountability & Malpractice
Standard of Care
The expected care, skill, & judgment under similar circumstances by a similarly trained, reasonable paramedic
Deviation from accepted or expected standards of care expected to protect from unreasonable risk of harm
Negligence
What are the required components for proof of a negligence claim in EMS?
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
Good Samaritan Law Government Immunity Statue of Limitations Contributory Negligence
Accountability & Malpractice
How do these affect the Paramedic’s Practice?
Borrowed Servant Doctrine Patient Civil Rights Liability when Off-Duty
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
Issues Surrounding Consent
Patient has legal & mental capacity Patient understands consequences Types of Consent
Informed Expressed Implied Involuntary
Specific Paramedic-Patient Issues
Issues Surrounding Consent
Specific Consent Issues
Minors Emancipated Minor Prisoners
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
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
Restraint
Definitions
Assault Battery False Imprisonment
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
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
Patient Abandonment
Unilateral termination of the patientprovider relationship
Still needed and desired MCI Risks to well-being
Exceptions
Can a paramedic turn over care of a patient to an EMT?
Specific Paramedic-Patient Issues
Transfer of Patient Care
Transfer of Care to other Providers Transfer of Care at the ED
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
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
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
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
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
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
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
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
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
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
Equipment Failure
Product Liability
Design flaw in ventilator
Failure on part of owner/operator
No backup battery for defibrillator
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
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
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
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
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
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
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
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
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
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
Patient Confidentiality Securing/Sharing/Requests for Information Protected Classes Quality & Effectiveness
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
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
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
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
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
There are many legal issues surrounding the EMS environment The paramedic should attempt to keep up-todate with local legal requirements Ignorance is not acceptable!
Suggested Reference
Cohn, B. M. Azzara, A. J. Legal Aspects of Emergency Medical Services. W. B. Saunders Company. 1998