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  1. 1. LEGAL ASPECTS OF Medical Care Prof. Syed Amin Tabish FRCP (London), FRCP (Edin.), FACP, FAMS, MHA (AIIMS) Postdoc Fellowship, Bristol University (England) Doctorate in Educational Leadership (USA)
  2. 2. Legal Aspects of Medical Practice • With knowledge explosion and technological advances mainly aimed to provide high quality medical care to individual patients, the need for a careful construction of a professional ethics is urgent. • Citizen’s charter on Health Services • Consumer Protection Act
  3. 3. Why Ethics •Patients are increasingly aware of what they believe to be their human rights & expect doctors to respect them
  4. 4. The Duties of Clinical Care Rights of patients may be summarized by 3 corresponding duties of care which apply to all patients: - Protect life & health - Respect Autonomy - Fairness & justice
  5. 5. 1. The Duties of Clinical care •Protect Life & Health (clinicians to practice medicine to high standard not to cause unnecessary harm/suffering)
  6. 6. 2. The Duties of Clinical Care Respect Autonomy: • Humans have autonomy – the ability to reason, plan and make choices about the future • Doctors are required to respect these attributes (respect for the dignity): - informed consent - confidentiality (per info) Denying pts. such choice & control robs them of their human dignity
  7. 7. 3. Fairness & justice • The access to & quality of clinical care should be need-based rather than favoritism • Injustice can occur through treating patients unequally according to: - socioeconomic status - physical attraction - profession - age - race Equal Access to appropriate care according to NEED
  8. 8. Why should Doctors take these duties seriously? • Professional regulation (Medical Council) • The Law (duties are also enshrined in the constitution/statue/common law) - Doctors may be sued in Civil Law for financial compensation for any harm (failure in professional duty) - If this harm is intentional: Criminal Law will apply
  9. 9. Why should Doctors take these duties seriously? • Rational Self-interest: support the right of all patients to high standard of care • The clinical importance of trust: lack of trust will spoil the quality of pt. care & professional life • The Doctor-Patient Relationship: treat pts. As active partners in healing process; Problem-solving is by doctors; Decision-making is by both (Doctor & Patient)
  10. 10. Medical Mistakes Clinical Negligence • Patient must provide evidence to the Court that: - they were harmed - the harm was caused by the accused doctor - the action that causes the harm was a breach of professional duty
  11. 11. Challenges • Consent • Medical negligence • Medical reports • Certificates • Sexual offenses • Confidentiality • Terminal illness • Withdrawing of life-support
  12. 12. Ethics is everyone’s responsibility • The relationship of patient to his physician is by its very nature one of the most intimate • Foundation: doctor is learned, skilled & experienced in afflictions of body about which patient ordinarily knows little (but are very imp for him)
  13. 13. Ethics is everyone’s responsibility • Patient must place great reliance, faith & confidence in the professional word/advice/acts of doctor • Doctor must act with utmost good faith & to speak fairly & truthfully to the peril of being held liable for damages for deceit or fraud
  14. 14. Fundamental Right • No person shall be deprived of his life (life with human dignity) • Emergency care is right of every citizen • When a person who is innocent or criminal has met with an accident, it is the obligation of health providers to protect his life
  15. 15. Legal Necessity • Every doctor under law bound by a contract to serve its patient and cannot refuse treatment. Every doctor has to fulfill certain legal requirements in service by compulsion or voluntarily as defined under law.
  16. 16. Building Confidence •A good working knowledge of the law in this regard, coupled with a thorough understanding of the correct method of dealing with legal aspects helps one to build confidence over riding the fear of LAW
  17. 17. Medical Laws • The Legal aspects of medical practice broadly covers two areas of medical laws: Medical Jurisprudence : It deals with legal aspects of medical practice. • Forensic Medicine : It deals with medical aspects of law.
  18. 18. Sources of Law • PRIMARY SOURCES: Laws passed by the Parliament or the State Legislative • Ordinances passed by the President and the Governor • Subordinate legislation: Rules and regulations made by the executive through the power delegated to them by the Acts. • SECONDARY SOURCES: Judgments of the Supreme Court, High Court and Tribunals (The ratio decedendi is a binding precedent) • Judicial legislation • Judgment of Foreign Courts • International Treaty
  19. 19. MEDICALETHICSANDCONDUCT • Apart from his routine and usual “clinical” cases, a doctor will come across certain ‘Medicolegal’ issues at one time or the other during the practice of his profession. • Duties and obligations of doctors are enlisted in the laws of the land and different Codes of Medical Ethics and Declaration:  Hippocratic Oath  Declaration of Geneva  Declaration of Helsinki on medical research  International Code of Medical Ethics
  20. 20. Declaration of Geneva • The Declaration of Geneva of the WMA binds the physician with the words, "The health of my patient will be my first consideration,“ and the International Code of Medical Ethics declares that, "A physician shall act in the patient's best interest when providing medical care
  21. 21. Legal responsibility of hospital • Hospital is a public institution • Deals with life and death • Hence carries specified responsibilities & liabilities within and outside the hospital • Failure to comply invites legal action • Legal responsibilities are bound to different category of people and institution by contracts • Breach of any contract held the hospital legally responsible
  22. 22. Emergency Doctrine • In Emergencies, CONSENT can be implied in the law if immediate treatment is necessary to avoid life- or limb-threatening condition • Clinical management should precede the legal duties in trauma cases brought for treatment
  23. 23. Medical Negligence • A doctor must posses a reasonable degree of proficiency & apply the proficiency with a reasonable degree of diligence • Failure of the doctor to provide medical services (with requisite skill & care) gives rise to action in medical negligence under criminal, civil or consumer court
  24. 24. Medical Negligence • A doctor is negligent if he doesn't offer his services in an emergency situation • A doctor breaches his duty of care when he fails to reach the standard of proficiency expected of him
  25. 25. Legal concept of Negligence • Human Behaviour towards others: failure to act reasonably & prudently • Failure or breach of duty owed to the patient doctor has the obligation to perform that duty in a manner that will bring it to a successful conclusion) • Damage to the individual for breach of duty (there must be some damage to the patient resulting from breach of duty owed)
  26. 26. Medical malpractice • The plaintiff must prove that the treatment given was below the degree and skill expected of a competent doctor and that the negligence proximately caused the injury or death……….. The bare possibility of causation will not suffice
  27. 27. TORT • Civil wrong (negligence) committed by one individual against another is known as TORT, where, a person fails to take proper care, so that damage results • Civil Law deals with legal actions which seek the redress of wrongs which are not criminal in nature • Criminal Law involves a legal action filed by a state government against defendants and deals with definitions of crimes and their punishment
  28. 28. Negligence • Harmful conduct that deviates from accepted standards of duty & care • A doctor who injures a patient by conduct that fails to meet the legal standard of due care may be liable for negligence in an action for malpractice
  29. 29. Specific elements of Negligence In order for a complaining party to sustain an action for negligence against a defending party, 4 elements must be proved in the court of law: • Existence of doctor-patient relationship giving rise to a duty of due care • Breach of that duty • Proximate cause (injury): Fall from a Stretcher in ED sustains bruises/MI after 4 months; is unlikely to rove that the fall caused MI • Damages
  30. 30. Res Ipsa Loquitur • In most malpractice cases, the plaintiff is required to prove negligence through the testimony of an expert medical witness • An exception: doctrine of res ipsa loquitur (the thing speaks for itself): when medical mishap could not be due to someone’s negligence (presence of a sponge or clamp in the body cavity of a patient who has had surgery is a self-evident indication of negligent conduct by some member of the operating team)
  31. 31. Error of Clinical Judgment • Some mishaps are unavoidable, being within the wide range of variability and uncertainty that is inherent in biological processes • Common causes for negligent actions include failure to attend, amputation of wrong limb or digit, missed fractures,, tight plaster casts, poor results from spinal procedures, damage to newborn from anoxia or forceps
  32. 32. Error of clinical judgment - II • Removal of healthy kidney instead of pathological • Operation on healthy eye • Leaving gauze or instrument in the body cavity during surgery • Anesthetic errors • Not performing sensitivity tests for certain drugs before administering • Failed tubal sterilization
  33. 33. Malpractice • Professional negligence • Lack of reasonable care & skill • Willful negligence in the treatment of a patient whereby the health or life of a patient is endangered
  34. 34. Criminal Negligence • Negligence is so great as to go beyond matter of mere compensation • Not only the doctor has made wrong diagnosis and treatment, but he/she has shown gross neglect for life and safety of the patient • Doctor may be prosecuted for having caused injury or death of a patient by a rash & negligent act amounting to culpable homicide
  35. 35. CONSENT • One of the most basic human rights is freedom from physical interference • A person of sufficient maturity and mental capacity can choose whether to submit to the ministrations of a doctor • With few exceptions, consent to examination is an absolute prerequisite before a doctor approaches the patient • Failure to obtain consent may lead to recovery of damages in a civil action
  36. 36. Battery •Battery: an unpermitted contact with the patient •A clinician who fails to obtain consent for treatment or who provides treatment beyond or contrary to what the patient has consented to
  37. 37. Types of Consent • Implied Consent: is provided by the behaviour of the patient; e.g. patient presents at Outpatient Clinic • Express Consent: Any thing other than implied consent. It may be oral or written • Informed Consent: consent must be obtained after a reasonable explanation of the proposed procedure to patient, so that he is enable to make informed decision whether or not to submit
  38. 38. The Extension Doctrine • Provides an exception to the general rule that a patient’s consent is limited to those procedures contemplated when consent is given • If in the course of authorized medical intervention a doctor discovers a life- threatening condition that requires immediate treatment and the patient is unable to consent (e.g. under anesthesia), the doctor may extend the operation or procedure without the patient’s express consent
  39. 39. Therapeutic privilege • A situation where full disclosure to the patient might be harmful and therefore contraindicated, a doctor may have a therapeutic privilege to withhold information • This privilege avails only when the patient’s distress and apprehension are so great that full disclosure of all risks might cause emotional harm or induce the patient to refuse treatment, fail to cooperate with treatment, or make an irrational choice of treatment alternatives • Used in rare circumstances only
  40. 40. Medical reports & certificates • Reports on the medical conditions of a person (victim or accused)folowing injury • Death certificate • Reports for Life-insurance • Certificate of illness • Certificate of fitness • All these documents must be prepared with meticulous accuracy
  41. 41. Sexual Assault (Rape) • Rape is a legal conclusion and not a medical diagnosis • The medical diagnosis of a rape victim should be limited to the actual clinical findings at the time of examination • If female Gynecologist fail to reach the fact definitely, or if circumstances so demand, take the judge permission to have the victim examined by male forensic doctor
  42. 42. Medical Exam. of a female The medical examination by a Gynecologist or Forensic Doctor of a woman subjected to sexual assault shall be done in presence of: • guardian • female general practitioner • nurse
  43. 43. Report Incidents requiring a report to the proper official relevant agencies while maintaining as much patient confidentiality as possible, include: • Drug & chemical poisoning • Road traffic accident • Gun-shot wounds • Physical assault
  44. 44. Gunshot & Stab Wounds •Reports of these acts of violence are usually made to police
  45. 45. Dead-on-Arrival • If the case of death is natural, death certificate & burying license must be submitted to relatives • Un-natural death: be reported to police for possible investigation & for assessment of need for a referral to forensic medicine sp. • Initiate resuscitation unless it is clear that patient has been dead for some time • Mention that deceased was brought dead • Body to be examined by a committee • In case there is no clear cause of death, take 50 ml blood in plain tube & send to Toxicology Centre
  46. 46. Cause of Death • In case the results (from toxicology lab) are negative, the cause of death can be mentioned as “Death possible due to hidden disease leading to cardiopulmonary arrest” • All dead bodies should be kept for 2 hours before transferring to mortuary • Patient’s belongings should be handed over to relatives, if the cause of death is natural.
  47. 47. Medico-legal cases • A case or injury or ailment where an attending doctor after taking history & clinical examination of the patient, thinks that some investigation by law-enforcing agencies are essential so as to fix responsibility regarding the case in accordance with the law of the land
  48. 48. Medico-legal cases • Motor vehicle accidents (RTAs) • Factory/industry accidents • Suspected homicide, suicide • Poisoning • Burn injuries • Injury where foul play is suspected • Sexual offenses • Unconscious cases where cause is not known • Cases brought dead with improper history • Cases referred by Court
  49. 49. MLC Injury Report • Must be prepared on the appropriate form • Should be written in a neat and legible handwriting by the examining doctor • Report should be completed as early as possible after examining the person • Time of examination along with date • Where nature of injury cannot be ascertained, patient must be kept under observation and admitted in ward • General physical examination should always be undertaken & findings recorded • Opinion will depend on X-ray & other reports
  50. 50. Preservation of trace evidence • All clothing worn by an injured and removed in the hospital shall be preserved, packed after drying • Gastric lavage, bullet pellets etc. taken out of the body of a patient be preserved in sealed containers & labeled properly, preserved under safe custody
  51. 51. Doctor’s Defence • When something untoward happens following a diagnostic or therapeutic procedure, the doctor must take following step/s: – complete the patient’s record & recheck the written notes – be frank enough and inform clearly of the mishap and show genuine concern about the unfortunate mishap – contact professional bodies to seek advice – professional indemnity insurance cover
  52. 52. Hospital: A Glimpse
  53. 53. Health Law • field of legal practice, scholarship and law reform relating to the delivery of health care • deals with health care delivery at macro and micro level • rapidly expanding and dynamic field - scientific, social, economic, legal, philosophical and political influences
  54. 54. Why Study Health Law? • all aspects of the practice of medicine, and healthcare more broadly, are affected by the law • important for physicians to have an awareness of how the law affects them and their patients • Medical Council of India expects competency in this area
  55. 55. Influences on Development of Health Law • health care reform movement (re organization and financing of health care system) • increasing litigation and new types of litigation – e.g. class action suits re medical devices – wrongful life lawsuits
  56. 56. Influences on the Development of Health Law • advances in science and technology – e.g. genetic research – reproductive technologies • advances in information technology – computerized patient information – vast amount of health info on the internet • evolution of field of bioethics, increasing influence of new perspectives
  57. 57. Law and Ethics • law influenced by ethics and to some extent the converse is true • obviously important to comply with the law, but what the law says may not be the ultimate answer to a moral question • many ethical principles re medical practice now codified - tends to blur the distinction (rules-based vs. virtue ethics) • some similarities in reasoning - clarifying facts, principles and their application
  58. 58. Overview of the Indian Legal System •where does the law come from? •areas of law •Indian constitutional framework •the court system
  59. 59. Sources of Law • Legislation –statutes –regulations –federal and provincial • Judicial Decisions –sometimes referred to as the “common law” –precedents
  60. 60. Nature of the Law •degree of uncertainty •role of judicial interpretation •constantly evolving
  61. 61. Divisions of Law • Public Law – disputes between individual and state – e.g. criminal law, administrative law, constitutional law • Private Law – sometimes referred to as “civil law” – disputes between individuals – e.g. torts, contracts, property law
  62. 62. Health Law Topics • Country’s health care system – structure, funding, supply of and access to health services • regulation of health professionals e.g. MD’s • medical negligence • consent • confidentiality and disclosure of health information
  63. 63. Health Law Topics • medical care of minors • medical care of patients with mental disabilities • abortion • regulation of reproductive technologies • genetics and the law • end of life decision making • medical research
  64. 64. Regulation of the Medical Profession • state responsibility • “self-regulating” professions • body created by statute in each province – e.g. Medical Board – standards for licensure – deals with allegations of incompetence, incapacity or misconduct – can generate its own policies, guidelines
  65. 65. Civil Liability • a.k.a. negligence, “malpractice”, “getting sued” • law in this area mostly “judge-made” • informed consent • standard of care
  66. 66. Complex Emerging Issues – e.g. reproductive technologies – electronic health care records - privacy issues – cost constraints - impact on insured services and on individual care • complex issues affected by several sources and divisions of law (courts, legislatures, federal, provincial, criminal, civil, Charter of Rights) as well as ethics, public policy
  67. 67. Laws Applicable to EMS • 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
  68. 68. Legal vs. Ethical vs. Moral Responsibilities • What are the differences? –Legal Responsibilities –Ethical Standards –Morality
  69. 69. The Legal System • Sources of Law – Constitutional – Common – Legislative – Administrative • Legislative and Administrative are often the focus of EMS Providers
  70. 70. 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?
  71. 71. The Legal System • Terminology –Plaintiff –Defendant –Discovery phase •Deposition •Interrogation •Documentation –Appeal
  72. 72. Laws Affecting EMS • Motor Vehicle Laws • Infectious Disease Exposure • Assault against Public Safety Officer • Obstruction of Duty • Good Samaritan Law: offering legal protection to an individual who voluntarily provides care during an emergency situation
  73. 73. Does India Need A Good Samaritan Law? • According to WHO accidents kill more than 200 people on roads every day in India. You must have awed at the number and must have even cursed the people who were the cause for such a loss. However do you know more than those rash drivers you are also one of the reason for such a loss.
  74. 74. 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
  75. 75. Accountability & Malpractice Issues • Standard of Care • Negligence • Civil Litigation Specifics • Borrowed Servant Doctrine • Patient Civil Rights • Liability when off-duty
  76. 76. Borrowed Servant Doctrine • The common law principle that the employer of a borrowed employee, rather than the employee’s regular employer, is liable for the employee’s actions that occur while the employee is under the control of the temporary employer.
  77. 77. 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?
  78. 78. 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
  79. 79. Defenses • Good Samaritan Law • Government Immunity • Statue of Limitations • Contributory Negligence
  80. 80. Accountability & Malpractice • How do these affect the Paramedic’s Practice? – Borrowed Servant Doctrine – Patient Civil Rights – Liability when Off-Duty
  81. 81. 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
  82. 82. Specific Paramedic-Patient Issues • Issues Surrounding Consent – Patient has legal & mental capacity – Patient understands consequences – Types of Consent • Informed • Expressed • Implied • Involuntary
  83. 83. Specific Paramedic-Patient Issues • Issues Surrounding Consent – Specific Consent Issues • Minors • Emancipated Minor • Prisoners
  84. 84. 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
  85. 85. 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
  86. 86. Specific Paramedic-Patient Issues • Restraint – Definitions • Assault • Battery • False Imprisonment
  87. 87. 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!
  88. 88. 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
  89. 89. 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?
  90. 90. Specific Paramedic-Patient Issues • Transfer of Patient Care – Transfer of Care to other Providers – Transfer of Care at the ED
  91. 91. 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
  92. 92. Specific Paramedic-Patient Issues • Advanced Directives & End of Life Decisions – Living Will – Durable Power of Attorney for Health Care – Out of Hospital DNR • Terminal Condition no longer required • Identification Devices • EMS requirements • Revocation Can a Paramedic honor an Advanced Directive (other than a DNR)?
  93. 93. 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
  94. 94. 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
  95. 95. 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
  96. 96. 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
  97. 97. 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 patient’s business. Since PCP is associated with HIV/AIDS, your coworker suspects this man is infected. Your coworker discusses this case with a friend (the patient’s employer) who then discusses this matter with your patient (his employee). (cont’d)
  98. 98. 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?
  99. 99. 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
  100. 100. 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
  101. 101. Operational Issues • Equipment Failure – Product Liability • Design flaw in ventilator – Failure on part of owner/operator • No backup battery for defibrillator
  102. 102. 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
  103. 103. 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
  104. 104. 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 driver’s 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. (cont’d)
  105. 105. Operational Issues • Vehicle Operation – What issues might the driver’s 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?
  106. 106. 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
  107. 107. 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
  108. 108. 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?
  109. 109. 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
  110. 110. 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?
  111. 111. 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”
  112. 112. Documentation • Patient Confidentiality • Securing/Sharing/Requests for Information • Protected Classes • Quality & Effectiveness
  113. 113. 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
  114. 114. 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?
  115. 115. 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
  116. 116. 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
  117. 117. 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?
  118. 118. 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!
  119. 119. Medical, Legal, and Ethical Issues
  120. 120. National EMS Education Standard Competencies (1 of 3) Preparatory Uses simple knowledge of the emergency medical services (EMS) system, safety/ well-being of the emergency medical responder (EMR), and medical/legal issues at the scene of an emergency while awaiting a higher level of care.
  121. 121. National EMS Education Standard Competencies (2 of 3) Medical/Legal and Ethics • Consent/refusal of care • Confidentiality • Advance directives • Tort and criminal actions • Evidence preservation • Statutory responsibilities
  122. 122. National EMS Education Standard Competencies Medical/Legal and Ethics (cont’d) • Mandatory reporting • Ethical principles/moral obligations • End-of-life issues
  123. 123. Introduction • Laws differ from one location to another, so EMRs should learn the specific laws that apply in their state or jurisdiction. • Do not lose sight of these concepts: – Above all else, do no harm. – Provide all your care in good faith. – Provide proper consistent care, be compassionate, and maintain your composure.
  124. 124. Duty to Act (1 of 2) • If you are employed by an agency as an EMR and you are dispatched to the scene of an accident or illness, you have a duty to act. – You must proceed promptly to the scene and render emergency medical care within the limits of your training and available equipment.
  125. 125. Duty to Act (2 of 2) • Failure to respond or render care leaves you and your agency vulnerable to legal action. Credit: © Corbis
  126. 126. Standard of Care • The standard of care is the manner in which you must act or behave. • You must meet two criteria: – You must treat the patient to the best of your ability. – You must provide care that a reasonable, prudent person with similar training would provide under similar circumstances.
  127. 127. Scope of Care • Scope of care is defined by: – The US Department of Transportation, Emergency Medical Responder Educational Standards – Medical protocols or standing orders – Online medical direction
  128. 128. Ethical Responsibilities and Competence (1 of 2) • Treating a patient ethically means doing so in a manner that conforms to accepted professional standards of conduct. – Stay up-to-date on skills and knowledge. – Review your performance and assess your techniques. – Evaluate your response times. – Take continuing education classes.
  129. 129. Ethical Responsibilities and Competence (2 of 2) • Ethical behavior requires honesty. – Always provide complete and correct reports to other EMS providers. – Never change a report except to correct an error.
  130. 130. Consent for Treatment (1 of 4) • Consent simply means giving approval or permission. • Expressed consent – The patient actually lets you know— verbally or nonverbally—that he or she is willing to accept treatment. – The patient must be of legal age and able to make a rational decision.
  131. 131. Consent for Treatment (2 of 4) • Implied consent – The patient does not specifically refuse emergency care. – Do not hesitate to treat an unconscious patient. • Consent for minors – Under the law, minors are not considered capable of speaking for themselves.
  132. 132. Consent for Treatment (3 of 4) • Consent for minors (cont’d) – Emergency treatment must wait until a patient or legal guardian consents to the treatment. – If permission cannot be quickly obtained, do not hesitate to give appropriate medical care.
  133. 133. Consent for Treatment (4 of 4) • Consent of mentally ill patients – If the person appears to be a threat to self or others, place this person under medical care. – Know your state’s legal mechanisms for handling these patients. – Do not hesitate to involve law enforcement agencies.
  134. 134. Patient Refusal of Care (1 of 2) • Any person who is mentally in control has a legal right to refuse treatment. • Help the person understand the consequences of refusing care by explaining: – The treatment – The reason that the treatment is needed – The potential risks if treatment is not
  135. 135. Patient Refusal of Care (2 of 2) • Patient refusals should be documented on your patient care record according to your agency protocols.
  136. 136. Advance Directives (1 of 3) • An advance directive is a document that specifies what a person would like to be done if he or she becomes unable to make his or her own medical decisions. • A living will – Written document drawn up by a patient, a physician, and a lawyer – States the types of medical care the person wants or wants withheld
  137. 137. Advance Directives (2 of 3) • A durable power of attorney for health care – Allows a patient to designate another person to make decisions about medical care • A do not resuscitate (DNR) order – Written request giving permission to medical personnel not to attempt resuscitation in the event of cardiac arrest
  138. 138. Advance Directives (3 of 3) • If you are unable to determine if an advance directive is legally valid, begin appropriate medical care. – Some states have systems in place, such as bracelets, to identify patients with advance directives.
  139. 139. Abandonment • Abandonment occurs when a trained person begins emergency care and then leaves the patient before another trained person takes over. • Once you have started treatment, you must continue it until a person who has at least as much training arrives and takes over.
  140. 140. Persons Dead at the Scene (1 of 2) • If there is any indication that a person is alive, you should begin providing care. • You cannot assume a person is dead unless one of these conditions exists: – Decapitation – Rigor mortis – Tissue decomposition
  141. 141. Persons Dead at the Scene (2 of 2) • If any of the signs of death are present, consider the patient to be dead. • It is important that you know the protocol your department uses in dealing with patients who are dead on the scene. Credit: © Damian Dovarganese/AP Photos
  142. 142. Negligence • Negligence occurs when a patient sustains further injury or harm because the care administered did not meet standards. • These conditions must be present: – Duty to act – Breach of duty – Resulting injuries – Proximate cause
  143. 143. Confidentiality (1 of 2) • Most patient information is confidential. – Patient circumstances – Patient history – Assessment findings – Patient care given • Information should be shared only with other medical personnel.
  144. 144. Confidentiality (2 of 2) • In certain circumstances, you may release confidential information to designated individuals. • Health Insurance Portability and Accountability Act of 1996 (HIPAA) – Strengthens laws for the protection of the privacy of health care information and safeguards patient confidentiality
  145. 145. Good Samaritan Laws • Protect citizens from liability for errors or omissions in giving good- faith emergency care • Vary considerably from state to state • May no longer be needed – Provide little or no legal protection for a rescuer or EMS provider
  146. 146. Regulations • Become familiar with the federal, state, local, and agency regulations that affect your job. • Certification or registration may be required to work as an EMR. • You are responsible for keeping certifications or registrations current.
  147. 147. Reportable Events (1 of 2) • Reportable crimes include: – Knife wounds – Gunshot wounds – Motor vehicle collisions – Suspected child or elder abuse – Domestic violence – Dog bites – Rape
  148. 148. Reportable Events (2 of 2) • Learn which crimes are reportable in your area. • Failure to notify proper authorities of reportable events may result in sanctions against you or your agency.
  149. 149. Crime Scene Operations (1 of 3) • Many emergency medical situations are also crime scenes. • Keep these considerations in mind: – Protect yourself. – If you determine that a crime scene is unsafe, wait until law enforcement personnel give you the signal that the scene is safe for entry. – Your priority is patient care.
  150. 150. Crime Scene Operations (2 of 3) • Considerations: (cont’d) – When you are assessing the scene, document anything that seems unusual. – Move the patient only if necessary. – Touch only what you need to touch to gain access to the patient. – Preserve the crime scene for investigation. – Do not cut through knife or bullet holes
  151. 151. Crime Scene Operations (3 of 3) • Considerations: (cont’d) – Be careful where you place equipment. – Keep nonessential people away. – Work with the appropriate law enforcement authorities on the scene. – Write a short report about the incident. Credit: © Bob Child/AP Photos
  152. 152. Documentation (1 of 3) • Your documentation is the initial account describing the patient’s condition and the care administered. – Serves as a legal record of your treatment – Provides a basis for evaluating the quality of care provided – Should be clear, concise, accurate, and readable
  153. 153. Documentation (2 of 3) • Documentation should include: – Condition of the patient when found – Patient’s description of the injury/illness – Patient’s initial and repeat vital signs – Treatment you gave the patient – Agency and personnel who took over treatment of the patient – Any reportable conditions present
  154. 154. Documentation (3 of 3) • Documentation should include: (cont’d) – Any infectious disease exposure – Anything unusual regarding the case
  155. 155. Summary (1 of 3) • As an EMR, you have a duty to act when you are dispatched on a medical call as a part of your official duties. • You should understand the differences between expressed consent, implied consent, consent for minors, consent of mentally ill persons, and the right to refuse care.
  156. 156. Summary (2 of 3) • Advance directives give a patient the right to have care withheld. • You should understand the concepts of abandonment, negligence, and confidentiality, as well as the purpose of Good Samaritan laws.
  157. 157. Summary (3 of 3) • Certain events that deal with contagious diseases, abuse, or illegal acts must be reported to the proper authorities. • Crime scene operations are a complex environment.
  158. 158. Review 1.Emergency medical responders have the legal duty to act: A.only when they are being compensated by a certified agency. B.if they witness an emergency scene while not on duty. C.even when outside of their response jurisdiction. D.if they are employed by an agency as EMRs.
  159. 159. Review Answer: D. if they are employed by an agency as EMRs.
  160. 160. Review 2.Patients are legally able to make a decision regarding their care if they: A. are of legal age according to state law. B. have injuries that are not life threatening. C. willingly accept transport to the hospital. D. have bystanders who can verify their competency.
  161. 161. Review Answer: A. are of legal age according to state law.
  162. 162. Review 3.EMRs have the ethical responsibility to: A. provide care only when a paramedic is present. B. discuss details of each case with their coworkers and families. C. transport all patients to the closest hospital. D. conform to accepted professional standards of conduct.
  163. 163. Review Answer: D. conform to accepted professional standards of conduct.