Paramedic Care: Principles & Practice Volume 1: Introduction to Paramedicine CHAPTER Fourth Edition...

Paramedic Care: Principles & PracticeParamedic Care: Principles & Practice

Volume 1: Introduction to ParamedicineVolume 1: Introduction to Paramedicine

CHAPTER

Fourth EditionFourth Edition

©2013 Pearson Education, Inc.Paramedic Care: Principles & Practice, 4th Ed.

Medical/Legal Aspects of Prehospital Care

7


Standard

• Preparatory (Medical/Legal and Ethics)


Competency

• Integrates comprehensive knowledge of EMS systems, the safety and 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.


Introduction

• Paramedics must:– Be familiar with legal issues they

encounter in field– Be prepared to make medical decisions

and appropriate legal decisions

• Laws vary state to state; protocols vary county to county.

• Specific legal question: rely on advice of attorney.


Legal Duties and Ethical Responsibilities

• As paramedic, you have legal duties to patient, crew, medical director, public.

• Based on accepted standards; set by statutes and regulations

• Best protection from liability:– Perform systematic patient assessment.– Provide appropriate medical care.– Accurate and complete documentation


Each EMS response has the potential of involving paramedics in the legal system. (© Glen E. Ellman)



• Ethical Responsibilities– Promptly respond to both physical and

emotional needs of every patient.– Treat all patients and their families with

courtesy and respect.– Maintain skills and medical knowledge.– Participate in continuing education

programs, seminars, refresher training.



• Ethical Responsibilities– Critically review your performance;

constantly seek improvement.– Report honestly and with respect for

patient confidentiality.– Work cooperatively with and respect

other emergency professionals.



• Ethical standards are not laws. – Principles that identify desirable conduct

by members of particular group

• Morality: principle of right and wrong as governed by individual conscience.



• The Legal System– Constitutional law: based on

Constitution of United States; protects people against governmental abuse.

– Common law (“case” or “judge-made”): society's acceptance of customs and norms over time; changes and grows over years.



• The Legal System– Legislative law (statutory): does not

come from court decisions; created by lawmaking or legislative bodies.

– Administrative law (regulatory): enacted by administrative or governmental agency at either federal or state level.



• The Legal System– Criminal law: crime and punishment.– Civil law: noncriminal issues (personal

injury, contract disputes, matrimonial issues). Plaintiff: person initiating litigation. Defendant: person against whom

complaint is made.



• The Legal System– Tort law: civil wrongs committed by one

individual against another.– Trial courts: judge or jury determines

outcome of individual cases.– Appellate courts: hear appeals of

decisions by trial or appeals courts.



• Anatomy of a Civil Lawsuit– Incident– Investigation– Filing of complaint– Answering of complaint– Discovery

Examination before trial (deposition) Interrogatory Requests for document production



• Anatomy of a Civil Lawsuit– Trial– Decision– Appeal– Settlement



• Laws Affecting EMS and the Paramedic– Scope of Practice

Range of duties and skills paramedics allowed and expected to perform

Set by state law or regulation and by local medical direction

Policy to guide paramedics in dealing with intervener physicians



• Laws Affecting EMS and the Paramedic– Certification: recognition granted to

individual who has met qualifications to participate in certain activity.

– Licensure: used to regulate occupations.– Understand EMS laws and regulations in

your state.



• Laws Affecting EMS and the Paramedic– Special motor vehicle laws govern

operation of emergency vehicles and equipment; vary state to state.

– Each state has different laws to protect public. Report spousal abuse, child abuse and

neglect, abuse of elderly, sexual assault, gunshot and stab wounds, animal bite, communicable diseases.



• Laws Affecting EMS and the Paramedic– Laws to protect paramedics:

Immunity: exemption from legal liability. Good Samaritan laws: immunity for

people who assist at medical emergency. Ryan White Comprehensive AIDS

Resources Emergency Act (Ryan White CARE Act): exposure to bloodborne or airborne pathogens.


Legal Accountability of the Paramedic

• Required to provide level of care to patients consistent with education and training; equal to other paramedics with equivalent training.

• Expected to perform duties in reasonable and prudent manner.– Intentional tort: civil wrong committed

by one person against another based on willful act.



• Negligence and Medical Liability– Negligence: deviation from accepted

standards of care recognized by law for protection of others against unreasonable risk of harm.


EMS Liability Claims



• Negligence and Medical Liability– Duty to act: formal contractual or

informal legal obligation to provide care. Duty to respond to scene and render care

to ill or injured patients Duty to obey federal, state, local laws

and regulations Duty to operate emergency vehicle

reasonably and prudently




informal legal obligation to provide care. Duty to provide care and transportation

to expected standard of care Duty to provide care and transportation

consistent with scope of practice and local medical protocols




informal legal obligation to provide care. Duty to continue care and transportation

through to appropriate conclusions



• Negligence and Medical Liability– Breach of duty:

Malfeasance: performance of wrongful or unlawful act by paramedic.

Misfeasance: performance of legal act in manner harmful or injurious.

Nonfeasance: failure to perform required act or duty.



• Negligence and Medical Liability– Res ipsa loquitur:

Complainant must prove damages would not have occurred in absence of somebody's negligence.

Instruments causing damages were under defendant's control at all times.

Patient did nothing to contribute to his own injury.



• Negligence and Medical Liability– Negligence per se (automatic):

paramedic violates statute and injury to plaintiff results.

– Actual damages: plaintiff must prove he was actually harmed in way that can be compensated by award of damages. Plaintiff may seek punitive (punishing)

damages.



• Negligence and Medical Liability– Proximate cause: action or inaction of

paramedic immediately caused or worsened damage suffered by plaintiff. Plaintiff needs to prove damage to

patient was reasonably foreseeable.



• Negligence and Medical Liability– Defenses to negligence:

Good Samaritan laws Governmental immunity Statute of limitations Contributory or comparative negligence



• Negligence and Medical Liability– Appropriate education, training,

continuing education– Appropriate medical direction– Accurate, thorough documentation – Professional attitude and demeanor – Act in good faith.– Use common sense.– Covered by medical liability insurance



• Special Liability Concerns– Paramedic's medical director: may be

liable to patient for negligent supervision of paramedic.

– Borrowed servant doctrine: if supervising other emergency care providers, liable for any negligent act they commit.



• Special Liability Concerns– Civil rights: patient may sue for violating

his civil rights if you fail to render care for discriminatory reason.

– Off-duty paramedic: liability may arise in situation in which off-duty paramedic renders assistance at scene.



• Special Liability Concerns– Airway issues: failure to secure airway

or failure to recognize airway improperly placed can result in devastating or fatal injuries for patient.

– Restraint issues: patient who must be physically or chemically restrained due to patient's behavior.



• Special Liability Concerns– Restraint issues:

Excited delirium syndrome (ExDS) Restraint or positional asphyxia.

– Understand and practice safe restraint techniques.

– Medical restraint is high-risk issue


Paramedic-Patient Relationships

• Confidentiality– Medical or personal information

(medical history, assessment findings, treatment) will not be released to third party without express permission of patient or legal guardian.



• Confidentiality– Patient consents to release of his

records.– Other medical care providers have need

to know.– EMS is required by law to release a

patient's medical records.– Third-party billing requirements



• Health Insurance Portability and Accountability Act (HIPAA)– Enhances confidentiality of medical

records– All EMS employees trained in HIPAA

compliance– Methods to ensure EMS personnel who

have been exposed to communicable disease notified in timely fashion.



• Defamation– Person makes intentional false

communication that injures another person's reputation or good name



• Libel– Act of injuring person's character, name,

or reputation by false statements in writing or mass media with malicious intent or reckless disregard for falsity of statements.



• Slander– Act of injuring person's character, name,

or reputation by false or malicious statements spoken with malicious intent or reckless disregard for falsity of statements.



• Invasion of Privacy– Release of confidential information,

without legal justification, regarding patient's private life; exposes patient to ridicule, notoriety, embarrassment.



• Consent– Consent: granting of permission to treat.– By law, you must get patient's consent

before you can provide medical care or transport.

– Patient must be competent to give or withhold consent.



• Consent– Informed consent: based on full

disclosure of information. Nature of illness or injury; recommended

treatments Risks, dangers, benefits of treatments Alternative treatment possibilities; risks,

dangers, benefits of accepting each one Dangers of refusing treatment and/or

transport



• Consent– Expressed consent: most common;

person directly grants permission to treat—verbally, nonverbally, in writing.

– Implied consent: patient requires emergency intervention but is mentally, physically, or emotionally unable to grant consent.



• Consent– Involuntary consent: court orders

patients to undergo treatment, even though they may not want it.

– Competent adult in police custody does not lose the right to make medical decisions for himself.



• Consent– Minor: consent obtained from parent,

legal guardian, court-appointed custodian.

– Emancipated minor: considered adult.– Competent adult may withdraw consent

for any treatment at any time; refusal must be informed.


Example of a “release-from-liability” form.



• Refusal of Service– Be sure patient legally permitted to

refuse care; must be competent adult.– Make multiple and sincere attempts to

convince patient to accept care.– Enlist help of others (family or friends)

to convince patient to accept care.



• Refusal of Service– Make certain patient fully informed

about implications of decision and potential risks of refusing care.

– Consult with on-line medical direction.– Have patient and disinterested witness

sign release-from-liability form.



• Refusal of Service– Advise patient he may call you again for

help, if necessary.– Attempt to get patient's family or friends

to stay with patient.– Document entire situation thoroughly on

patient care report.



• Problem Patients– Violent– Victim of drug overdose– Intoxicated adult or minor– Ill or injured minor with no adult

available to provide consent for medical treatment



• Problem Patients– Attempt to develop trust and rapport.– Refusal form should be completed and

witnessed by police officer.– If situation dangerous, police officers or

family should consider legal measures.– Conversation with patient and refusal

witnessed by disinterested third party.



• Boundaries Issues– Professional boundaries: ethical and

societal limits to interactions between paramedics or health care personnel and patients they serve. Crossing professional boundaries can

result in breaching responsibilities.



• Boundaries Issues– Danger zones:

Being tired: fatigue can lead to problems (medication errors, poor decision making, vehicle crashes).

Being seduced: led away from one's principles, ethics, faith, allegiance.

Being unprepared



• Legal Complications Related to Consent– Abandonment: termination of

paramedic-patient relationship without providing for continuation of care while still needed and desired by patient.



• Legal Complications Related to Consent– Assault: unlawfully placing person in

apprehension of immediate bodily harm without his consent.

– Battery: unlawful touching of another individual without his consent.



• Legal Complications Related to Consent– False imprisonment: intentional and

unjustifiable detention of person without his consent or other legal authority; may result in civil or criminal liability.



• Reasonable Force– Minimum amount of force necessary to

ensure patient does not cause injury to himself, you, or others. Use of excessive force can result in

liability for paramedic. Force used as punishment considered

assault and battery.



• Reasonable Force– Use of restraints may be indicated for

combative patient.– Restraints conform to local protocols.– Restraining devices: straps, jackets,

restraining blankets.– Use least amount of force to safely

control patient while causing him least amount of discomfort.


Patient restraint is a high-risk endeavor. The safety of personnel and the patient should be the highest priority.



• Patient Transportation– Maintain same level of care as was

initiated at scene.– Emergency vehicle operations: be

familiar with state and local laws.– Patient choice of destination and

insurance company protocols– Facility selection based on patient

request, patient need, facility capability


Resuscitation Issues

• You are under obligation to begin resuscitative efforts when patient unresponsive, pulseless, apneic.

• Resuscitation not indicated:– Do Not Resuscitate (DNR) order– Obviously dead; obvious tissue

decomposition; extreme lividity– Scene too hazardous to enter.



• Advance Directives– Document to ensure certain treatment

choices honored when patient is unconscious or otherwise unable to express choice of treatments. Living wills, durable powers of attorney

for health care, Do Not Resuscitate orders, organ donor cards



• Advance Directives– Living will: legal document that allows

person to specify the kinds of medical treatment he wishes to receive should need arise.



• Advance Directives– Do Not Resuscitate (DNR) order: legal

document that indicates to medical personnel which, if any, life-sustaining measures should be taken when patient's heart and respiratory functions have ceased. Valid DNR orders should be honored as

your protocols allow.



• Advance Directives– Potential Organ Donation

Organs and tissues in very high demand and short supply

EMS systems vital link in organ procurement and transplant process

Consult on-line medical direction when you have identified potential donor.



• Death in the Field– Must be appropriately dealt with and

thoroughly documented. – Follow state and local protocols.– Contact on-line medical direction for

guidance.


Crime and Accident Scenes

• If you believe crime committed on scene, immediately contact law enforcement if not already involved.

• Protect yourself and safety of other EMS personnel; primary consideration.

• Once crime scene deemed safe, initiate patient contact and medical care.



• Do not move or touch anything at crime scene unless necessary for patient care.

• Do your best to protect potential evidence.

• If you need to remove items from scene, be sure to document your actions and notify investigating officers.



• Treat scene of accident in same way.• Ensure your own safety and safety of

your crew.• Treat patients as medically indicated.• Use resources available to you.


Duty to Report

• When abuse or neglect suspected, you must balance need to protect patient confidentiality against need to notify proper authorities.

• Act with patient's best interest in mind.• Many states have rules that require

EMS personnel to report suspected abuse to proper authorities.


Duty to Report

• Do not confront abuser. • Not necessary for you to prove abuse or

neglect occurred before reporting.• Failure to report abuse or neglect

bigger liability than reporting.


Documentation

• Well-documented Patient Care Report– Completed promptly after patient

contact– It is thorough.– It is objective.– It is accurate. – It maintains patient confidentiality.


Documentation

• Complete well-written patient care report is your best protection in malpractice action.

• If patient care report incomplete or inaccurate, a written amendment should be attached.

• Medical records maintained for period of time prescribed by state law.


Template-driven electronic patient records are becoming more common in modern EMS.


Employment Laws

• Employment laws address employee/employer relationships.

• Volunteer agencies fall under jurisdiction of many of these laws.

• Can be complex; consult attorney should problem arise


Employment Laws

• Americans with Disabilities Act: prohibits discriminating against qualified individuals with disabilities.

• Title VII: federal law prohibits workplace harassment and discrimination.


Employment Laws

• Amendments to Title VII– Equal Employment Opportunity Act of

1972– Age Discrimination and Employment Act

of 1967 (ADEA)– Age Discrimination Act of 1975


Employment Laws

• Family and Medical Leave Act of 1993 (FMLA)

• Fair Labor Standards Act (FLSA): minimum wage, overtime pay, recordkeeping, child labor standards.

• Occupational Safety and Health Act (OSHA): healthy and safe environment.


Employment Laws

• The Ryan White Care Act: funds programs to improve availability of health care for victims of AIDS and their families.


Summary

• Paramedic's job: interaction with law enforcement authorities; involvement in situations that give rise to litigation.

• Learn and follow all state laws and local protocols.

• Receive good training.• Keep current: continuing education

programs, industry journals, recertification or relicensure.


Summary

• Always obtain informed consent before initiating treatment and/or transport.

• Practice skills and procedures that reasonable and prudent paramedic would, given same or similar circumstances.


Summary

• Practice procedures you are trained to perform and are directly authorized to perform by medical control physician or approved local standing orders.

• Prepare accurate, legible, complete medical records that thoroughly document EMS incident.


Summary

• Discuss patient information with only those who need to know.

• Purchase and maintain malpractice insurance; employer does same.

• Be nice to patients and their families.• Act in good faith; use common sense.• High-quality patient care and

documentation are best protection from liability.

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