Medical Legal Nate Green, FF/PM Anchorage Fire Department

Medical LegalMedical Legal

Nate Green, FF/PM Nate Green, FF/PM

Anchorage Fire Department Anchorage Fire Department

ObjectivesObjectives

After this presentation you should be able After this presentation you should be able to:to: Identify common legal terms.Identify common legal terms. Understand who has medical/legal rights and Understand who has medical/legal rights and

how they obtain them. how they obtain them. Understand the difference in legal rights.Understand the difference in legal rights. Understand how these medical rights pertain Understand how these medical rights pertain

to patient care. to patient care.

Power Of AttorneyPower Of Attorney

Creates an agent that gives them authority Creates an agent that gives them authority to make legal decisions and carry them to make legal decisions and carry them out on your behalf.out on your behalf.

Two types: Two types: General P.O.A: Covers broad aspects.General P.O.A: Covers broad aspects. Specific P.O.A: Chooses certain aspects that Specific P.O.A: Chooses certain aspects that

the person wants.the person wants. Agents can be immediately recognized or Agents can be immediately recognized or

delayed depending on disability. delayed depending on disability.

Alaska LawsAlaska Laws

Alaska has special additional laws that Alaska has special additional laws that pertain to addressing health care advance pertain to addressing health care advance directives.directives.

Health care agents are assigned to make Health care agents are assigned to make general and specific health care decisions general and specific health care decisions on the patients behalf; i.e., end of life on the patients behalf; i.e., end of life treatment decisions and living wills. treatment decisions and living wills.

Alaska Laws (cont.)Alaska Laws (cont.)

Because someone has a legal P.O.A., it Because someone has a legal P.O.A., it doesn’t necessarily make them a health doesn’t necessarily make them a health care agent as well. care agent as well.

Additional provisions regarding health care Additional provisions regarding health care directives must be filled out by the patient directives must be filled out by the patient and checked on the P.O.A form.and checked on the P.O.A form.

Alaska Advanced Health care Alaska Advanced Health care Directive Directive

An advance directive allows you to have a An advance directive allows you to have a say in how you want to be treated if you say in how you want to be treated if you become very ill. In the document, you can become very ill. In the document, you can choose a health care agent, choose the choose a health care agent, choose the kind of health you want, and choose to kind of health you want, and choose to make an anatomical gift (organ/tissue make an anatomical gift (organ/tissue donation.donation.

Living WillLiving Will

A living will is one type of health care A living will is one type of health care directive. In the document, you can outline directive. In the document, you can outline the type of care that you want if in the the type of care that you want if in the event you become ill. A living will is usually event you become ill. A living will is usually not as detailed as an advance directive. not as detailed as an advance directive.

Advance Directives and Living WillsAdvance Directives and Living Wills

Can be filled out and created at any point Can be filled out and created at any point in life. You do not necessarily have to be in life. You do not necessarily have to be sick or ill. sick or ill.

Advanced DirectivesAdvanced Directives

Durable power of attorney for health care.Durable power of attorney for health care. This essentially creates the designation of This essentially creates the designation of

an agent to make health care decisions for an agent to make health care decisions for you. you.

Gives the agent full control of your health Gives the agent full control of your health care. care.

The Alaska Advanced Health Care The Alaska Advanced Health Care Directive is broken down into the following Directive is broken down into the following 5 parts. 5 parts.

Part 1Part 1

Consent or refuse any care, treatment Consent or refuse any care, treatment procedure to maintain, diagnose, or procedure to maintain, diagnose, or otherwise affect a physical or mental otherwise affect a physical or mental condition.condition.

Select or discharge health care providers Select or discharge health care providers and institutions.and institutions.

Part 1 (cont.)Part 1 (cont.)

Approve or disapprove diagnostic test, Approve or disapprove diagnostic test, surgical procedures and medications.surgical procedures and medications.

Direct the use of artificial hydration and Direct the use of artificial hydration and nutrition and all other forms of healthcare.nutrition and all other forms of healthcare.

Make the decision on anatomical gifts Make the decision on anatomical gifts following your death. following your death.

Sections ContinuedSections Continued Part 2 Part 2

Gives you specific instructions to dictate how or what Gives you specific instructions to dictate how or what care you would like. care you would like.

Part 3 Part 3 Lets you express an intention to make an anatomical Lets you express an intention to make an anatomical

gifts following your death. gifts following your death. Part 4 Part 4

Lets you make decisions in advance about certain Lets you make decisions in advance about certain types of mental heath treatment. types of mental heath treatment.

Part 5Part 5 Allows you do designate a physician to have primary Allows you do designate a physician to have primary

responsibility for your health care. responsibility for your health care.

Advance DirectivesAdvance Directives

You have the right to revoke, advance You have the right to revoke, advance health care directives or replace the form health care directives or replace the form at any time. at any time.

You loose power to revoke when you are You loose power to revoke when you are deemed incompetent by a court, or by two deemed incompetent by a court, or by two physicians, at least one whom shall be a physicians, at least one whom shall be a psychiatrist. psychiatrist.

Alaska Comfort One ProgramAlaska Comfort One Program

Established into law in 1996. Established into law in 1996. Helps health care providers identify terminally-ill Helps health care providers identify terminally-ill

people who have expressed these wishes. people who have expressed these wishes. The program established a protocol for health The program established a protocol for health

care providers to respect these wishes once the care providers to respect these wishes once the person has been identified as being enrolled in person has been identified as being enrolled in the program.the program.

DNR Protocol (7 AAC 16.010-7AAC 16.090)DNR Protocol (7 AAC 16.010-7AAC 16.090)

Definition of Health Care ProviderDefinition of Health Care Provider

Health care provider means a person who Health care provider means a person who is licensed, certified or otherwise is licensed, certified or otherwise authorized or permitted by law to provide authorized or permitted by law to provide health care in the ordinary course of health care in the ordinary course of business or practice of a profession. business or practice of a profession.

Comfort OneComfort One

For the purpose of the statue, an individual For the purpose of the statue, an individual who is authorized to administer CPR who is authorized to administer CPR appears to fall within the definition of a appears to fall within the definition of a “health care provider” in AS 13.52.390(23) “health care provider” in AS 13.52.390(23) with respect to activities related to CPR. with respect to activities related to CPR.

Consequently, even those providers Consequently, even those providers authorized to administer only limited health authorized to administer only limited health care must, by statue, respect the Comfort care must, by statue, respect the Comfort One form ,wallet card or bracelet. One form ,wallet card or bracelet.

Comfort One (cont.)Comfort One (cont.)

Proof of Enrollment forms. Proof of Enrollment forms. Printed form containing patients name, address, date Printed form containing patients name, address, date

of birth and gender. of birth and gender.

To be valid the form must be signed by both a To be valid the form must be signed by both a physician and the patient if the patient is able. physician and the patient if the patient is able.

Patients generally have the form or two of the Patients generally have the form or two of the other approved pieces of identification of other approved pieces of identification of enrollment.enrollment. Wallet CardsWallet Cards BraceletsBracelets


A DNR may only be revoked by the A DNR may only be revoked by the following people: following people: The patient.The patient. The patient’s physician.The patient’s physician. The parent or guardian of a DNR patient if the The parent or guardian of a DNR patient if the

patient enrolled in the Comfort One Program patient enrolled in the Comfort One Program is under the age of 18.is under the age of 18.


Confirm the patient’s identity in these acceptable Confirm the patient’s identity in these acceptable manners:manners: Patient can communicate their name.Patient can communicate their name. Identification arm band.Identification arm band. Patient being personally known to physician or other Patient being personally known to physician or other

health care provider.health care provider. Patient’s family member(s) on location.Patient’s family member(s) on location. Patient’s driver’s license.Patient’s driver’s license. Dispatch notifies you they have a valid Comfort One Dispatch notifies you they have a valid Comfort One

on file for that patient/address.on file for that patient/address.


Once the patient’s identity and DNR status Once the patient’s identity and DNR status have been confirmed:have been confirmed: If the patient is pulseless and apenic and If the patient is pulseless and apenic and

does not have a valid DNR begin resuscitation does not have a valid DNR begin resuscitation efforts. efforts.

If the patient does have a valid DNR, If the patient does have a valid DNR, resuscitation efforts should not be initiated or resuscitation efforts should not be initiated or if already in progress should be terminated if already in progress should be terminated immediately. immediately.

Patients with Out of State DNRPatients with Out of State DNR

A DNR order issued in another state, A DNR order issued in another state, territory or possession of the Unites states territory or possession of the Unites states is valid if it complies with Alaska law. is valid if it complies with Alaska law.

A health care provider can presume, in the A health care provider can presume, in the absence of actual notice to the contrary, absence of actual notice to the contrary, that a DNR order and identification is valid, that a DNR order and identification is valid, and treat the patient in accordance with and treat the patient in accordance with the Alaska Comfort One protocol. (AS the Alaska Comfort One protocol. (AS 13.52.150)13.52.150)

AFD Comfort One PoliciesAFD Comfort One Policies

When AFD responds to an expected home When AFD responds to an expected home death or Comfort One patient: death or Comfort One patient: EMT or MICP will carefully evaluate pulse and EMT or MICP will carefully evaluate pulse and

respiration before verbal confirmation of death respiration before verbal confirmation of death is reported to APD, AFD dispatch or the is reported to APD, AFD dispatch or the patient’s family. patient’s family.

ECG is not required nor is it preferred.ECG is not required nor is it preferred.

AFD Comfort One Policies (cont.)AFD Comfort One Policies (cont.)

Physical findings must be documented Physical findings must be documented completely on the patient care report.completely on the patient care report.

If the patient still has measurable vital signs If the patient still has measurable vital signs and the family requests transport without and the family requests transport without resuscitation an AFD MICU will transport to a resuscitation an AFD MICU will transport to a receiving facility. receiving facility.


It is the responsibility of the EMT or MICP to It is the responsibility of the EMT or MICP to assess the needs of the family for emotional assess the needs of the family for emotional support and ascertain whether logistical support and ascertain whether logistical assistance in dealing with the deceased is assistance in dealing with the deceased is required.required.

Chaplain may be contacted through AFD Chaplain may be contacted through AFD dispatch to assist the family or caregivers of dispatch to assist the family or caregivers of the patient at the discretion of the EMT or the patient at the discretion of the EMT or MICP. MICP.


Comfort One expected home deaths, with Comfort One expected home deaths, with valid DNR orders on scene or on file with valid DNR orders on scene or on file with dispatch, and after confirmation of death and dispatch, and after confirmation of death and proper notifications have been made it is proper notifications have been made it is permissible to leave the patient with the permissible to leave the patient with the family. family.

Law Enforcement ResponseLaw Enforcement Response

In the event of an expected home death In the event of an expected home death with valid DNR paperwork APD is not with valid DNR paperwork APD is not required to respond. required to respond.

In the event something on scene seems In the event something on scene seems suspicious with the death an APD officer suspicious with the death an APD officer should be requested. should be requested.

Law Enforcement Response (cont.)Law Enforcement Response (cont.)

Title 12. Code of Criminal Procedure Title 12. Code of Criminal Procedure Chapter 12.65. Death investigations and Chapter 12.65. Death investigations and

Medical examiners. Section 12.65.007.Medical examiners. Section 12.65.007.


A peace officer is not required by state law A peace officer is not required by state law to respond to the scene of an expected to respond to the scene of an expected home death if:home death if: The death was expected to occur due to the The death was expected to occur due to the

deceased state of health before death.deceased state of health before death. The death occurred at the deceased’s home The death occurred at the deceased’s home

as expected due to the deceased’s state of as expected due to the deceased’s state of health.health.


A person authorized to determine and A person authorized to determine and pronounce death determines and pronounce death determines and pronounces the death:pronounces the death: A form signed by the deceased’s physician A form signed by the deceased’s physician

concerning the physician's expectation that concerning the physician's expectation that the death would occur due to the person's the death would occur due to the person's state of health and that it would occur at home state of health and that it would occur at home was, at the time of death, on file with the law was, at the time of death, on file with the law enforcement agency for that jurisdiction. enforcement agency for that jurisdiction.


When Law enforcement does need to When Law enforcement does need to respond.:respond.: 11-29 Expected Home death when no DNR is 11-29 Expected Home death when no DNR is

available or patient is not under hospice.available or patient is not under hospice. Often this happens when people either Often this happens when people either

forget to fill out the paperwork, never fill forget to fill out the paperwork, never fill out the paperwork or the death happens out the paperwork or the death happens very suddenly or quicker than expected.very suddenly or quicker than expected.

Hospice CareHospice Care

Program that provides comfort care at the Program that provides comfort care at the end of life through intensive symptom end of life through intensive symptom management, and support of patient/family management, and support of patient/family identified goals of care. identified goals of care.

Hospice care for adults with a life limiting Hospice care for adults with a life limiting illness and prognosis of less than six illness and prognosis of less than six months. The goal is to improve the quality months. The goal is to improve the quality of life for the patient and family.of life for the patient and family.

Hospice Care (cont.)Hospice Care (cont.)

Hospice patients are generally Comfort Hospice patients are generally Comfort One patients and do not require transport One patients and do not require transport to the ED unless an health care agent to the ED unless an health care agent requests this. requests this.

Generally if the hospice nurse is not on Generally if the hospice nurse is not on location of a scene contacting them is location of a scene contacting them is easy and very valuable to the health care easy and very valuable to the health care provider in the event you need questions provider in the event you need questions answered.answered.

Alaska MOSTAlaska MOST

Medical Orders for Scope of TreatmentMedical Orders for Scope of Treatment Generally at the Pioneer Home and similar Generally at the Pioneer Home and similar

facilities. facilities. If applicable, have company officer or If applicable, have company officer or

other healthcare provider ask for MOST other healthcare provider ask for MOST form. Continue treatments as indicated on form. Continue treatments as indicated on the form.the form.

Breaks down treatment options into 4 Breaks down treatment options into 4 simple categories.simple categories.

Alaska MOST (cont.)Alaska MOST (cont.)

Treatment Section A.Treatment Section A. Treatment options when the person is not Treatment options when the person is not

breathing and has no pulsebreathing and has no pulse Do Not attempt Resuscitation.Do Not attempt Resuscitation. Attempt Resuscitation/CPR.Attempt Resuscitation/CPR.

Alaska MOST (cont.)Alaska MOST (cont.)

Treatment Section B: Treatment options when Treatment Section B: Treatment options when the person has a pulse and is breathing. the person has a pulse and is breathing. Comfort Measures Only: Medication, positioning and Comfort Measures Only: Medication, positioning and

other measures to relieve pain and suffering. Use other measures to relieve pain and suffering. Use oxygen, suction and manual treatment of airway oxygen, suction and manual treatment of airway obstruction as needed for comfort. obstruction as needed for comfort.

Do not transport for life sustaining treatment.Do not transport for life sustaining treatment. Only transport if comfort needs cannot be met at Only transport if comfort needs cannot be met at

current location.current location.

Treatment Section B (cont.)Treatment Section B (cont.)

Limited Interventions: Use care above as well as Limited Interventions: Use care above as well as medical treatment, IV and cardiac monitor as medical treatment, IV and cardiac monitor as appropriate. Transfer to ED if appropriate. These appropriate. Transfer to ED if appropriate. These patients avoid ICU if possible.patients avoid ICU if possible.

Trial of Intensive Therapy. Includes care above Trial of Intensive Therapy. Includes care above including trial of intubation, ventilator. including trial of intubation, ventilator.

Full treatment. ACLS,Intubation,Ventilation Full treatment. ACLS,Intubation,Ventilation cardioversion etc.cardioversion etc.

Treatment Sections C and DTreatment Sections C and D

Last two items not in the scope of EMS.Last two items not in the scope of EMS. Relates to antibiotic use and artificial Relates to antibiotic use and artificial

nutrition. nutrition.

AFD Policies AFD Policies

Obvious Death/Decision Not to Obvious Death/Decision Not to resuscitate.resuscitate.

First arriving crew to begin resuscitation First arriving crew to begin resuscitation on any patient without pulse or on any patient without pulse or respirations unless one or more of the respirations unless one or more of the following signs are present. following signs are present.

If there is ANY DOUBT whether or not the If there is ANY DOUBT whether or not the patient meets this criterions, then CPR patient meets this criterions, then CPR with BLS adjuncts shall be initiated. with BLS adjuncts shall be initiated.

AFD PoliciesAFD Policies

Resuscitative efforts shall continue until Resuscitative efforts shall continue until the first arriving MICP or EMT determines the first arriving MICP or EMT determines that the patient is beyond resuscitation that the patient is beyond resuscitation and/or an emergency department and/or an emergency department physician is contacted and consulted.physician is contacted and consulted.

Criteria #1Criteria #1 Evidence of a non-recent death.Evidence of a non-recent death. Rigor Mortis-Caused by chemical changes Rigor Mortis-Caused by chemical changes

to the muscle after death causing the to the muscle after death causing the muscles to stiffen. This is only valid if muscles to stiffen. This is only valid if hypothermia is not a factor.hypothermia is not a factor.

Dependent Lividity-settling of the blood in Dependent Lividity-settling of the blood in dependent portion of the body resulting in dependent portion of the body resulting in a purplish red discoloration of the skin.a purplish red discoloration of the skin.

Any evidence of decomposition.Any evidence of decomposition.

Criteria # 2Criteria # 2

Explosive gunshot wound or wounds to Explosive gunshot wound or wounds to the head. the head.

Criteria # 3Criteria # 3

Severe injury obviously incompatible for Severe injury obviously incompatible for life.life.

Criteria #4Criteria #4

Submersion greater than one hour.Submersion greater than one hour.

Criteria 5Criteria 5

Suspected death due to hypothermia with Suspected death due to hypothermia with the following signs:the following signs: Core Temp<60 degrees.Core Temp<60 degrees. Patient has ice in the airway.Patient has ice in the airway. Generalized total body frozen skin/tissue Generalized total body frozen skin/tissue

which is more than localized frostbite.which is more than localized frostbite.

ProcedureProcedure

First arriving unit determines patient is First arriving unit determines patient is beyond resuscitation and notifies dispatch beyond resuscitation and notifies dispatch person is 11-29. person is 11-29.

First arriving EMT/MICP will confirm initial First arriving EMT/MICP will confirm initial assessment and gather information for assessment and gather information for paperwork and report. paperwork and report.

Life Alaska information will be gathered Life Alaska information will be gathered and phoned to dispatch.and phoned to dispatch.

Exceptions to this policyExceptions to this policy

Triage decisions in multi patient incidents.Triage decisions in multi patient incidents. Inability to gain access to the scene or patient. Inability to gain access to the scene or patient.

EntrapmentEntrapment Law Enforcement will not allow access. Attempt to get Law Enforcement will not allow access. Attempt to get

badge number/name of officer.badge number/name of officer. Situations that would place rescuers/AFD personnel Situations that would place rescuers/AFD personnel

in grave danger. in grave danger. Decisions based upon direct consultation with an Decisions based upon direct consultation with an

emergency room physician, or with an identified MD emergency room physician, or with an identified MD on scene. Delays in Physician contact must be fully on scene. Delays in Physician contact must be fully documented.documented.

DocumentationDocumentation

The first arriving MICP or EMT shall The first arriving MICP or EMT shall complete a patient care report, specifically complete a patient care report, specifically recording the physical findings which recording the physical findings which support the decision not to resuscitate support the decision not to resuscitate based on the criteria established in this based on the criteria established in this policy.policy.

Document any consultations with ED with Document any consultations with ED with time and name of MD spoken with. time and name of MD spoken with.

Patients Unresponsive to CPRPatients Unresponsive to CPR

Decisions to discontinue advanced life Decisions to discontinue advanced life support resuscitation measure in the field support resuscitation measure in the field once underway require consultation with once underway require consultation with an emergency room physician. an emergency room physician.

Document time, whom you spoke to and Document time, whom you spoke to and hospital in the PCR. hospital in the PCR.

Traumatic Cardiac ArrestsTraumatic Cardiac Arrests

Resuscitation efforts should be withheld in Resuscitation efforts should be withheld in victims of penetrating or blunt trauma with victims of penetrating or blunt trauma with injuries obviously incompatible with lifeinjuries obviously incompatible with life Decapitation.Decapitation. Hemicorporectomy.Hemicorporectomy. Significant time lapse since pulselessness. Significant time lapse since pulselessness.

Blunt TraumaBlunt Trauma

Resuscitation efforts may be withheld in Resuscitation efforts may be withheld in any blunt trauma patient who, based upon any blunt trauma patient who, based upon a MICP’s thorough primary patient a MICP’s thorough primary patient assessment, is found:assessment, is found: Pulseless and apneic.Pulseless and apneic. Asystolic in ECG Leads I,II, III.Asystolic in ECG Leads I,II, III.

Penetrating TraumaPenetrating Trauma

Resuscitation efforts may be withheld in Resuscitation efforts may be withheld in any penetrating trauma patient who, based any penetrating trauma patient who, based upon a MICP’s thorough primary patient upon a MICP’s thorough primary patient assessment, is found: assessment, is found: Pulseless and apneic.Pulseless and apneic. Absence of papillary reflexes or spontaneous Absence of papillary reflexes or spontaneous

movement.movement. Asystolic in ECG leads I,II,III.Asystolic in ECG leads I,II,III.

Traumatic ArrestsTraumatic Arrests

Cardiopulmonary arrest patients in whom Cardiopulmonary arrest patients in whom the mechanism of injury does not correlate the mechanism of injury does not correlate with clinical condition, suggesting a non-with clinical condition, suggesting a non-traumatic cause of the arrest, should have traumatic cause of the arrest, should have standard resuscitation initiated.standard resuscitation initiated.

Traumatic ArrestsTraumatic Arrests

Termination of resuscitation efforts should be Termination of resuscitation efforts should be considered in trauma patients with EMS-considered in trauma patients with EMS-witnessed cardiac arrest and 15 minutes of witnessed cardiac arrest and 15 minutes of unsuccessful resuscitation and CPR.unsuccessful resuscitation and CPR.

Traumatic cardiac arrest patients with a Traumatic cardiac arrest patients with a transport time to an emergency department of transport time to an emergency department of more than 15 minutes after the arrest is more than 15 minutes after the arrest is identified may be considered non-salvageable, identified may be considered non-salvageable, and termination of resuscitation should be and termination of resuscitation should be considered. considered.

SUIDSUID(Sudden Unexpected Infant Death)(Sudden Unexpected Infant Death)

PolicyPolicy In recognition of CDC guidelines concerning In recognition of CDC guidelines concerning

death scene investigation for victims of SUID it death scene investigation for victims of SUID it shall be the policy of the Anchorage Fire shall be the policy of the Anchorage Fire Department Department not not to transport those patients to transport those patients under twelve months of age believed to have under twelve months of age believed to have expired as a result of sudden infant death expired as a result of sudden infant death syndrome in circumstances when no syndrome in circumstances when no resuscitation efforts have been undertaken. resuscitation efforts have been undertaken.

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Medical Legal Nate Green, FF/PM Anchorage Fire Department