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OutlineOutline Responsibilities ~ Legal, Ethical, Moral
Overview of the Legal System
Specific Laws Accountability & Malpractice Specific Paramedic-Patient Issues Operational Issues
Documentation
ResponsibilitiesResponsibilities
Legal Responsibilities Established by the law-making bodies of government i.e. DUI, Homicide
Ethical Standards Principles of conduct identified by members of a group or profession i.e. “First do no harm”
Individual Morality Individual’s assessment of right & wrong i.e. “right-to-life”
Legal SystemLegal System Law
Constitutional Common Legislative Administrative
EMS most affected by legislative & administrative laws
Court SystemsCourt Systems Federal
Most powerful and widest-reaching i.e. “Constitutional Law”
State Can be overridden by Federal law i.e. “same-sex” marriage over-turned by US courts
Criminal Illegal acts; can be state or federal i.e. breaking & entering
Civil i.e. divorce law
Terminology Plaintiff
Person bringing lawsuit
Defendant Person answering charges/ lawsuit
Discovery Deposition Interrogation Documentation
Appeal Bringing case to higher court when court’s decision is questioned
EMS-Specific LawsEMS-Specific Laws Scope of Practice
Direct vs Indirect Medical Direction “Intervener” physician
Ability to Practice Certification vs Licensure Authorization to Practice
Other Laws Motor Vehicle
Infectious Disease Exposure
Assault against Public Safety Officer
Obstruction of Duty
Good Samaritan Law
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 Standard of Care
Negligence
Civil Litigation
Borrowed Servant Doctrine
Civil Rights
Off-Duty Liability
Standard of Care
“Expected care, skill, & judgment under similar circumstances by a similarly trained, reasonable paramedic.”
Established nationally, regionally, locally
Documentation demonstrating standard of care will save your butt!
NegligenceNegligence “Deviation from accepted or expected
standards of care expected to protect from unreasonable risk of harm.”
To prove: Did not act when there was a Duty to Act Breach of duty Damage or harm resulted from health care provider’s actions Proximate cause
Civil Cases Proof of guilt from “preponderance of evidence”
“Res Ipsa Loquitur” Burden of proof shifts to the defendant
Simple vs. Gross Negligence
Defenses Good Samaritan Law
Government Employees Immunity CIA, FBI…not so much Fire Personnel (sorry)
Statue of Limitations
Contributory Negligence
Accountability & Malpractice How do these affect the your Practice?
Borrowed Servant Doctrine
Patient Civil Rights
Liability when Off-Duty
Paramedic-Patient Issues Consent Refusals Restraint Abandonment Transfer of Care
Advance Directives End of Life Decisions Out of Hospital Death Confidentiality Privacy
Consent Patient has legal & mental capacity
Any suggestion of AMS negates capacity
Patient understands consequences
Types: Informed Expressed Implied
Consent Issues Minors
Who is an “Emancipated Minor” in Ohio?
Prisoners
Mental Retardation
Mental Health Disease
Refusals Consent for transport vs treatment
Withdrawl of Consent
Refusal of Service must ALWAYS document with witness:
Legal & mental capacity Is informed of risks & benefits Offer alternatives
Who Cannot Refuse Care? Unable to understand nature & consequences of
injury or illness
Unable to make rational decisions regarding medical care due to physical or mental conditions
Danger to self &/ or others
Do not assume incompetence unless obvious Politicians aside…and then it is generally obvious!
Restraints Prepare to spend a whole lot of time documenting
Always have a law enforcement report as a “witness” to your report
Does not provide authorization to harm! Risk being charged with: Assault Battery False Imprisonment
Patients under arrest can refuse treatment & transport unless condition exists preventing them from making a rational decision
Restraints Involve Law Enforcement early
Have a plan of action
Ensure safety of all
Reasonable force
Physical & chemical restraints
Document well
Patient Abandonment Unilateral termination of patient-provider
relationship when still required & / or desired by one party
Exceptions MCI Risks to well-being
Advanced Directives & End of Life Decisions Advanced Directive
Out of Hospital DNR
Living Will
Durable Power of Attorney for Health Care
Patient Self-Determination Act
Important Points About End of Life Decisions Not a surrender of rights to receive medical care
Comfort measures appropriate
Provide Family support and guidance
When in doubt, resuscitate & contact medical control
Termination of efforts allowed
Out of Hospital Death Initiation of care?
Some states & regions require: Law enforcement response Justice of the peace, medical examiner or coroner
pronouncement
Requires medical control
Survivors/ family may become patients
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 most States, QA/QI is not discoverable
Patient Confidentiality & Privacy Colleague & Station Chat
Cannot identify the patient & must maintain confidentiality of specific medical information
Scene or Patient Photographs ? Cell phones ? Media
EMS Radio Dispatch & Discussions
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
Equipment Failure Product Liability
i.e. ventilator design flaw
Failure on part of owner/operator No backup battery for defibrillator
Crime Scenes Request law enforcement & await their arrival
Minimize personnel & their scene contact
Document alterations to scene created by EMS
Document pertinent observations
Evidence Preservation Avoid cutting through penetrations in the clothing
Save everything found on victim
Do no discourage sexual assault patient from washing
Can be considered “coercion”
Chain of evidence procedures i.e. document turnover of possessions
Vehicle Operation The greatest source of EMS-related law-
suits
The greatest percentages of wins for the plaintiff and/ or EMS “settlements”
Vehicle Operation – Case Study While responding to a MVC at 0300, a driver fails
to yield the right of way at an intersection
The driver’s traffic signal is green. You attempt to stop but are unable to causing injury to the driver
Witnesses state your emergency lights were on but do not recall hearing your siren
Issues For The Driver’s Attorney Were 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 maintenance is performed on your ambulance?
Did you exercise due regard for the safety of others? Historical investigation as well
Medical Control Issues
Failure to follow medical control
Following harmful medical control direction Includes Medical Control directing EMS to inappropriate hospital Includes Following direction of unauthorized person
Implementing therapies without prior authorization
The paramedic exceeds the scope of his training or medical authorization
Instructor Liability Discrimination
Sexual harassment
Student injury
Failure to properly train graduate or supervise student
Best defense: Follow curriculum Document attendance Document competency
Hospital Selection Paramedic & Medical Control decision
Closest vs “Most Appropriate” Facility
Written policies or guidelines
Dispatch Untimely dispatch
Untimely response Failure to provide correct address
Dispatch of inadequate level of care
Failure to provide pre-arrival instructions
Inadequate recordkeeping
Interfacility Transfer Appropriate equipment & training?
Travel with specialized providers?
Printed patient report?
Is patient “stable”? Potential complications with decompensation?
Are there any specific physician orders?
Has the patient been accepted? Documented and confirmed transferring & accepting physicians?
OSHA & Risk Management If you live & work in an OSHA-regulated State…
“Each employee shall comply with occupational safety and health standards and all rules, regulations, & orders issued pursuant to this Act which are applicable to his own actions and conduct”
Documentation Confidentiality
Security
Sharing QA, research, M & M
Protected Classes
Quality & Effectiveness
Confidentiality
Written report intended only for those with need to know
Personal identifiers generally removed for QA/QI
Radio reports should never contain personal identifiers Including terms like “frequent flyer”
Securing & Sharing Information
Where are patient reports stored?
Who receives the report at the ED?
Requests for copies must be routed through an accepted policy or an attorney
Does requestor have a need to know? No, No, No!: Media Yes: Patient, Family on behalf of patient, Lawyers,
Insurance/ billing companies (sometimes)
Protected Classes
Some specific disease information is considered confidential in a PCR
Tuberculosis HIV/ AIDS/ STDs
“Mandatory Reporting” is an issue for hospitals
Quality Documentation Complete immediately after the patient contact
Be thorough, accurate, honest, objective & factual
Caution with abbreviations
Maintain confidentiality
Do not alter once written down May always add an addendum
Important Points Does your chart tell an accurate story relating the events
that happened in a clear, concise format?
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?
Your PCR can be “called” into court without you!
Summary There are many legal issues
surrounding EMS & fire services
Health care providers should keep up-to-date with local legal requirements
Ignorance of the law is neither an excuse or acceptable!
References Cohn, B. M. Azzara, A. J. Legal Aspects of Emergency
Medical Services. W. B. Saunders Company. 1998
Temple College Division of EMS website
Page, Wolfberg & White Attorney’s webpage Lawyers who only handle EMS cases All lawyers are also paramedics Great free stuff on site