Legal and Ethical Aspects of Emergency

Medical Services

Lesson Goal

• Outline potential ethical dilemmas & provide simple approach to resolving those dilemmas

• Identify & define legal implications of working in EMS

Introduction

• Many laws & ethical principles apply to EMS work http://www.dphhs.mt.gov/ems/

• Be aware of how these issues relate to decisions

Scope of Potential Liability

• Medical errors—8th leading cause of death

• 50,000-100,000 Americans die each year because of medical errors

Scope of Potential Liability

• EMTs operate in unique environment

• Most lawsuits in EMS arise from vehicle accidents

• Root cause of many lawsuits—EMT’s attitude & behavior

Key Areas of EMS Law

• Levels of certification

• Training requirements

• Scope of practice

• Standard of care

• Requirements for certification

• Complaints against providers

• Disciplinary actions

• Legal protection

• Patients’ rights

• Emergency vehicle operations

• Workplace safety

EMT’s Responsibility

• Appropriate, timely, compassionate care

• Reporting of crimes– Child abuse– Elder abuse

• Ethical dilemmas—common

Duty to Act & Standard of Care

• Primary ethical responsibility– Provide appropriate care

• On call• Good Samaritan

• Standard of Care– Clinical & technical standards trained to

perform

Guiding Ethical Principles

• Patients’ autonomy

• Patients’ best interests

• First, do no harm

• Fairness

Ethical Issues

• What is a “good quality of life”?

• Organ donation

Handling Unethical Situations

• Consider your own beliefs

• Promote workplace culture of honesty, integrity, & communication

Negligence

• Ordinary negligence

4 elements• Duty to act• Breach of duty• Causation• Harm

Negligence

• Immunity defense– Good Samaritan laws

• Gross negligence– Always act in good faith

Negligence

• Personal risk management– Be well educated– Be well rested– Know & follow protocols– Maintain skills & knowledge

Attitudes & Communication

• Create a positive impression– Well rested & alert– Professional appearance– Confidence– Empathy– Communication skills

Attitudes & Communication

• Get on patient’s level• Introduce yourself• Explain what you are

doing• Reassure patient• Do not make false

promises• Provide basic comfort• Communicate with

family

Attitudes & Communication

• Smile• Use comforting tone• Avoid extraneous chatter• Be efficient• Say goodbye at end of call

ABANDONMENT

• Terminating care without legal excuse.

• Turning pt. over to lesser qualified personnel

Consent

• Must be obtained

Implied• Limited to Limited to TRUE EMERGENCYTRUE EMERGENCY situations situations

– UnconsciousUnconscious

– DelusionalDelusional

– UnresponsiveUnresponsive

– Physically unable to express consentPhysically unable to express consent

– MinorsMinors

Expressed/actual -Consent must be “informed”Consent must be “informed”

– permission for care of her/himselfpermission for care of her/himself

Refusal

• Competency—legal status

• Decision-making capacity—clinical determination

Refusal

• Ethics– Patient must be informed of meaning &

consequences of refusal– The time informed refusal takes is

worthwhile

Refusal

• Make sure patient understands– Treatment– Risks– Alternatives– Consequences of not being treated

Refusal

• Considerations– Make sure patient understands– Make reasonable attempts to persuade

patient– Make sure decision is not coerced– Document discussion– Know who can refuse on patient’s behalf– Err on side of treatment

Refusal

• Legally– Patients’ rights to self-determination– Assessing decision-making capacity– Patients can refuse some or all

interventions

Refusal

• A3E3P3 Guidelines– 3 As

• Assess• Advise• Avoid

Refusal

• A3E3P3 Guidelines– 3 Es

• Ensure• Explain• Exploit (uncertainty)

Refusal

• A3E3P3 Guidelines– 3 Ps

• Persist• Protocols• Protect

– Refusal signed– Documentation

“Law enforcement on scene on our arrival. Pt. had been unresponsive prior to EMS arrival per Sgt. Ulrickson. On EMS arrival Pt. was awake, agitated and refused assessment, treatment or transport. No injuries noted on visual assessment. Pt. denied injury. Stated he laid down on sidewalk to ‘take a power nap’. Pt. able to move all extremities equally—insisted on standing up. Gait unsteady. Alert to time, place, date. Refusal signed. Pt. advised he could call EMS or seek further medical assistance at any time. Pt. escorted home by friends.”

Living Wills & Advance Directives

• Advance directives

– Living wills

– Durable power of attorney

– DNR orders

Advance Directives in Montana EMS

• Comfort One

• POLST

Scope of Practice Issues

• Definition: procedures, actions, and processes that are permitted for the licensed individual—limited to that which the law allows for education, experience, and competency.

• EMS providers must always act within their scopes of practice

Documentation

• The patient care report (PCR)– Has many purposes– Is a reflection on YOU– Includes written and verbal

Patients’ Rights

Confidentiality & privacy are both legal and ethical issues

Patients’ Rights

• HIPAA

• Policies for release of PCRs

• Superprotection

Patients’ RightsRestraints—When and How

• When patient is physical threat to himself or others.

• Contact medical control, if possible.

• Restrain as little as possible.

• Involve Law Enforcement, if necessary.

Circa 1752

Incident Reports

• Unusual occurrences

• Prevent recurrences– Individuals– System

Future of EMS Law

• Anticipate regulations as profession matureshttp://www.dphhs.mt.gov/ems/

– Reduce potential for litigation• Professional approach• Reduce errors• Maintain training• Team work

Summary

• EMTs act within an ethical & legal context

• Common issues– Certification/licensure– Scope of practice– Consent & refusal– Negligence– Resuscitation decisions

Summary

• Lawsuits– Vehicle collisions– Breech of confidentiality– EMTs’ behavior & attitudes– Personal responsibility & risk reduction

QUESTIONS??