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 Certification or Licensure Authorization to Practice

Ability 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 Paramedics 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 patients business. Since PCP is associated with HIV/AIDS, your coworker suspects this man is infected. Your coworker discusses this case with a friend (the patients employer) who then discusses this matter with your patient (his employee). (contd)

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 No backup battery for defibrillator

Failure on part of owner/operator

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 drivers 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. (contd)

Operational Issues

Vehicle Operation

What issues might the drivers 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