Advanced Directives and Medical-Legal Issues

Advanced Directives and DNR Orders

• Advanced directives may be invalid in prehospital settings if they contain conflicting instructions (e.g., requesting medication but not CPR).
• DNR orders must clearly describe withheld interventions.
• Valid DNR orders require a witness and physician signature.
• DNR orders have a time limit for validity.
• DNR orders do not imply "Do Not Treat."
• For terminally ill patients, verify legal directives before withholding resuscitation.

Medical-Legal Issues

• Assault and Battery:
  • Assault: Placing someone in fear of immediate harm.
  • Battery: Unlawful touching without consent.
  • Restraining a patient without consent is both battery and false imprisonment.
• Negligence:
  • Transporting patients to the hospital helps prevent negligence claims.
  • Transfer patients to equally or more skilled personnel to avoid abandonment.
• Informed Consent:
  • Patients need clear, non-technical explanations.
  • A competent adult can withdraw consent at any time.
  • Family consent is not valid for competent adults.
• Child Abuse:
  • Report suspicious injuries (e.g., cigarette burns) as potential abuse.
• Vehicular Manslaughter:
  • Killing someone using an emergency vehicle is a criminal offense.

Ethics in EMS

• Core Ethical Principles:
  • Autonomy: Respect patient care decisions.
  • Beneficence: Act in the patient's best interest.
  • Nonmaleficence: Avoid causing harm.
  • Justice: Treat all patients fairly.
• Decision-Making Framework:
  • Use impartiality and universalizability tests to evaluate decisions.
  • Ethical frameworks like relativism, deontology, and consequentialism can help in dilemmas.
• Professional Boundaries:
  • Maintain ethical boundaries to avoid misconduct.
  • Recognize red flag behaviors in patients or providers.
• Confidentiality:
  • Protect patient privacy; share only as required by law.

Research and Evidence-Based Practice

• Purpose of Research:
  • Improve patient outcomes (reducing morbidity and mortality).
  • Enhance EMS systems and interventions.
• Types of Research:
  • Quantitative: Measurable data (e.g., statistical analysis).
  • Qualitative: Exploring reasons and experiences.
  • Mixed-method: Combining both quantitative and qualitative approaches.
• Ethical Research Considerations:
  • The Nuremberg Code and Helsinki Declaration safeguard participant safety and informed consent.
  • Institutional Review Boards (IRBs) approve and monitor studies.
• Levels of Evidence:
  • Randomized controlled trials (RCTs) are highly valid.
  • Meta-analyses offer stronger conclusions by combining multiple studies.

Key Legal and Administrative Notes

• Administrative Law:
  • Created by government agencies, often based on legislative laws.
• Termination of Resuscitation:
  • Criteria: Patient is 18+, valid advanced directives or legal authorization.
• Hospice Care:
  • Families often grieve before the patient's death, facilitating acceptance of terminal outcomes.

Practical Tips for EMS Providers

• Evidence Handling: Preserve evidence (e.g., use paper bags for bloody items).
• Scene Considerations: Limit physical examination unless essential (e.g., severe bleeding).
• Transport Decisions: [Specifics about transport decisions are not provided in the text.]