Medical/Legal Aspects of Prehospital Care

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Medical/Legal Aspects of Prehospital Care

• Department of EMS Professions
• Temple College

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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

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Legal vs. Ethical vs. Moral Responsibilities

• What are the differences?
• Legal Responsibilities
• Ethical Standards
• Morality

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Legal vs. Ethical vs. Moral Responsibilities

• Legal Responsibilities
• Established by the law-making bodies of
  government
• Ethical Standards
• Principles of conduct identified by members of a
  group or profession
• Morality
• Individuals assessment of right and wrong

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The Legal System

• Sources of Law
• Constitutional
• Common
• Legislative
• Administrative
• Legislative and Administrative are often the
  focus of EMS Providers

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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?
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The Legal System

• Terminology
• Plaintiff
• Defendant
• Discovery phase
• Deposition
• Interrogation
• Documentation
• Appeal

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Laws Affecting EMS

• Scope of Practice
• Texas
• Medical Direction
• Intervener physician
• Ability to Practice
• Certification or Licensure
• Authorization to Practice

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Laws Affecting EMS

• Motor Vehicle Laws
• Infectious Disease Exposure
• Assault against Public Safety Officer
• Obstruction of Duty
• Good Samaritan Law
• Ryan White CARE Act

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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

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Accountability Malpractice Issues

• Standard of Care
• Negligence
• Civil Litigation Specifics
• Borrowed Servant Doctrine
• Patient Civil Rights
• Liability when off-duty

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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?
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Accountability Malpractice

• Elements Required to prove Negligence
• Duty to Act
• Breach of duty
• Actual damage or harm
• Proximate cause

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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

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Defenses

• Good Samaritan Law
• Government Immunity
• Statue of Limitations
• Contributory Negligence

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Accountability Malpractice

• How do these affect the Paramedics Practice?
• Borrowed Servant Doctrine
• Patient Civil Rights
• Liability when Off-Duty

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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

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Specific Paramedic-Patient Issues

• Issues Surrounding Consent
• Patient has legal mental capacity
• Patient understands consequences
• Types of Consent
• Informed
• Expressed
• Implied
• Involuntary

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Specific Paramedic-Patient Issues

• Issues Surrounding Consent
• Specific Consent Issues
• Minors
• Emancipated Minor
• Prisoners

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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

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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

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Specific Paramedic-Patient Issues

• Restraint
• Definitions
• Assault
• Battery
• False Imprisonment

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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!

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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

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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?
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Specific Paramedic-Patient Issues

• Transfer of Patient Care
• Transfer of Care to other Providers
• Transfer of Care at the ED

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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

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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)?
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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

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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

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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

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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

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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)

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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?

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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

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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

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Operational Issues

• Equipment Failure
• Product Liability
• Design flaw in ventilator
• Failure on part of owner/operator
• No backup battery for defibrillator

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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

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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

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Operational Issues

• Vehicle Operation
• It is 300 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)

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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?

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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

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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

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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?
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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

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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?

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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

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Documentation

• Patient Confidentiality
• Securing/Sharing/Requests for Information
• Protected Classes
• Quality Effectiveness

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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

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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?

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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

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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

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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?

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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!

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Suggested Reference

• Cohn, B. M. Azzara, A. J. Legal Aspects of
  Emergency Medical Services. W. B. Saunders
  Company. 1998