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

Medical/Legal Aspects of Prehospital Care

Department of EMS ProfessionsTemple 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

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 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


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!


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 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 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


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)?


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


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


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?


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-to-date 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

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

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