Emergency Care: Consent and Decision Making

Introduction to Emergency Care

• A core principle is to avoid further harm.
• Adhering to your scope of practice and training standards can prevent legal issues.
• Lawsuits for monetary compensation can still occur even with proper care.

Understanding Consent

• Consent is required to provide care
• Treatment requires consent from the individual.
• A patient has the right to refuse care if conscious, rational, and capable of informed decisions.
• Decision-making capacity is fundamental for consent.
• Patients should be able to understand information and make informed decisions about medical care.
• Patient autonomy gives individuals the right to make their own healthcare choices.

Factors Affecting Decision-Making Capacity

• Consider intellectual capacity impairments (e.g., mental limitations, dementia).
• Check if the patient is of legal age.
• Determine if the patient is impaired by substances, injuries, or illness.
• Assess if the patient is experiencing significant pain or distracting injuries.
• Look for hearing, visual, or language barriers.
• Ensure the patient understands you through their questions and comprehension.

Types of Consent

• Expressed consent occurs when a patient explicitly agrees to care or transport.
• Informed consent requires explaining the treatment, risks, benefits, alternatives, and consequences of refusal.
• Implied consent applies when patients are unconscious or incapable of rational decisions.
• Implied consent is valid for serious conditions with life or limb threats.
• "Emergency doctrine" is the principle behind implied consent.
• Relatives' consent should be sort after prior to acting on implied consent
• Involuntary consent is used for mentally ill, behaviorally challenged, or developmentally delayed individuals.
• Consent should be get from a guardian or conservator, if possible
• Protective custody statutes in many states permit law enforcement to take these individuals to medical facilities.

Minors and Consent

• Parents or legal guardians typically provide consent for minors.
• Minors can give consent in some states.
• An emancipated minor is someone under the legal age but considered an adult.
• Emancipation criteria include marriage, military service, parenthood, or independent living.
• Teachers/school officials may act in place of parents (in loco parentis) for school/camp injuries.
• Implied consent applies in genuine emergencies without available consent.

Forcible Restraint

• Forcible restraint is permissible for combative patients needing treatment who pose a risk to themselves or others.
• Medical control authorization and law enforcement assistance are required for forcible restraint.
• Restraining without legal authority can lead to civil and criminal penalties.
• Local laws/protocols on forcible restraint need to be known
• Once applied, do not remove restraints en route unless the patient's safety is at stake.
• Chemical pharmacologic restraint may be given after consultation with ALS backup.

Patient's Right to Refuse Treatment

• Conscious, alert adults with decision-making capacity can refuse treatment, even if it leads to death or serious injury
• They are able to withdraw from treatment at any moment
• Refusal situations often lead to EMS litigation so adherence to local protocols/policies is essential.
• Online medical control should be contacted, and the consultation should be documented
• The patient's decision needs to be based on provided information such as:
  • Assessment findings.
  • Necessary treatments.
  • Risks of treatment.
  • Alternative treatments.
  • Consequences of refusal.
• The ability to make an informed decision must be assessed and documented:
  • Repeating inquiries.
  • Assessing responses.
  • Observing behavior.
• Confusion, delusions, or suicidal ideation negates informed refusal.
• Providing treatment is more defensible than failing to act when in doubt.
• Do not endanger yourself to provide care.
• Before leaving, encourage the patient/caregiver to accept treatment.
  • Advise a call to 9-1-1 if they change their mind.
  • Advise contact with their physician.
  • Request signing a refusal form.
  • Secure a witness.
  • Document refusals.

Confidentiality Rules

• Patient communication is confidential.
• Confidential data includes:
  • Patient history
  • Assessment findings
  • Treatment details
• Releasing data inappropriately can lead to liability.
• Disclosure of information without authorization is a breach of confidentiality.
• In most states, information may be released if:
  • The patient signs a release.
  • A legal subpoena is presented.
  • Billing requires it.

HIPAA

• HIPAA contains privacy rules for strengthing privacy laws
• It provides guidance on information protection:
  • Types of protected information.
  • Responsibilities of health providers.
  • Penalties for violations.
• All patient data during treatment is protected health information (PHI).
• PHI is medical and identifying information.
• Civil or criminal action can result from HIPAA violations.
• The general public can record identifying/protected data and images.

Considerations for Social Media

• While off duty, official spokespersons should avoid showing logos, uniforms, or markings
• Maintain your professional conduct while engaging in social media activities.
• Respect patients, family, friends, coworkers, and organizations when on or offline.
• Free speech does not allow for saying things without repercussions.

About Advanced Directives

• You may visit scene where patient is dying
• Family may not want resuscitation
• A Do Not Resuscitate (DNR) order allows withholding resuscitation.
• DNR does mean no treatment.
• Supportive measures are required such as oxygen, pain relief, and comfort to a patient who is not in cardiac arrest, whenever possible.
• Ambulance services have protocols for DNR orders
• Advanced directives are written instructions for medical care if a patient loses decision-making capacity.
• Common for comatose patients.
• Could be known as a living will or healthcare directive

DNR Order Requirements

• A valid DNR order should have:
  • Clear medical problem statement
  • Patient/legal guardian signature
  • Physician/licensed provider signature(s)
  • Must be dated within 12 months to be valid
• Physician Orders for Life-Sustaining Treatment (POLST) and Medical Orders for Life-Sustaining Treatment (MOLST) are seen when dealing with the terminally ill
• Medical orders should describe acceptable interventions for the patient.
• It must contain valid signature by authorized medical provider
• Contact medical control for advice, if needed
• Some patients can name surrogates that can give consent in the event the patient no longer can
• Durable powers of attorney for healthcare, known as health care proxies, make decisions for the patient

Physical Signs of Death

• Physician responsibility is to determine the cause of death
• Presumptive signs of death:
  • No response to pain.
  • Absence of pulse or heartbeat.
  • Absence of chest movement
  • Absence of reflexes.
  • Absence of pupillary reactivity
  • No systolic blood pressure
  • Profound cyanosis
  • Low body temperature
• Definitive signs of death:
  • Mortal injury such as decapitation
  • Dependent lividity that causes blood settling, and skin changing color
  • Rigor mortis that is stiffening caused by chemical changes, occuring 2-12 hours after death
  • Algor mortis is cooling of the body to room temperature
  • Putrefaction of body tissues takes 40-96 hours

Medical Examiner Cases

• Medical examiner involvement depends on death's nature/scene.
• Medical examiners/coroners must be notified in situations that are:
  • Patient dead on arrival (DOA).
  • Death without prior medical care or physician unable to determine cause.
  • Suicide.
  • Accidental/violent death.
  • Known/suspected poisoning
  • Suspicion of a criminal act.
  • Deaths of infants and children.
• Limit disturbing scene.
• Document everything and make notes.

Special Situations

• Organ donors state their wish to donate.
• Donor card/driver's license provides proof.
• Potential donors get treatment like any other patient.
  • Saving a life
  • Oxygen required
• Medical identification insignia: Bracelets/necklaces/cards with DNR orders, allergies, or other serious medical issues help EMS assessment/treatment.
• Some wear USB bracelets, often PDF files

Scope of Practice

• It outlines what type of care to provide
• State law typically defines it
• The medical director of the developing protocols or standing orders, further describes it
• Medical directors give care through radio, telephone or standing orders
• Negligence can result from exceeding it

Standards of Care

• A Standard of care is conducting yourself in the manner you should
• Conduct yourself how someone of similar training would act
• Standard of care is established through local custom, how an ordinary person would act in that situation
• Standard imposed by law happens through the Medical Practices Act.
• Professional conduct happens through standards of emergency medical care through statutes, ordinances, administrative regulation, or case law.
• Institutional standards happen through American Heart Association's standard for BLS and CPR
• Those standards are imposed by textbooks like National Highway Traffic Safety Administration (NHTSA) -States impose standards through Medical Practices Act

Duty to Act

• Providing patient care is a personal duty
• Following an ambulance call, duty to act is legally required
• You are not legally required to respond, if off duty, however know local laws and policies pertaining to duty

Negligence

• Negligence: failure to provide the same care that a person with similar training would provide.
• Four Negligence Factors:
  • Duty, give care that is consistent with established standard of care
  • Breach of duty happens when not acting with reasonable care
  • Damages, psychological or physical action toward a patient in a noticeable way.
  • Casuation, relationship between breach of duty and damages suffered by a patient
• Res ipsa loquitur is EMT held liable if action took place that was due to negligence.
• Negligence per se theory is in which someone who violates statute can be sued
• Torts are civil wrongs outside the jurisdiction of criminal courts

Abandonment

• Abandonment occurs when EMT stops care without consent and does not have provisions for medical professional
• By starting patient care, duty to act starts
• If patient is transferred in emergency department or elsewhere, that is abandonment
• Need to have another person sign patient care record

Assault, Battery, and Kidnapping

• Assault is making a person believe they have fear of bodily harm, such as threatening to restrain a patient
• Battery is touching a person unlawfully such as without consent
• Kidnapping is seizing, confining, abducting, or carrying away by force which be transporting patient against their will
• Unauthorized confinement is making a person falsely imprisoned.
• Legal situations may arise if consent is not given or is recinded

Concerns about Defamation

• False information is defamation
• Written false statement is libel, such as patient care report
• Spoken defamation is slander such as at station house

Good Samaritan Laws and Immunity

• Good Samaritan laws is an act of helping another person in good-faith that results in not being held liable for errors or omissions
• Protections involve:
  • Acting in good-faith
  • Providing care without compensation
  • Did not exceed scope of practice.
  • Did not act in a grossly negligent manner.
• Gross negligence is wilful or reckless
• Immunity statues apply to EMS that are government related.
• Sovereign immunity offers limitations and immunity

Records and Reports

• Agency must maintain records of all incidents.
• Important Legal Safeguard
• Perception that if action not recorded, it did not happen
• Incomplete records are seen as evidence of an emergency care.
• National EMS Information System (NEMSIS): Collect, store, and share data nationally.

Special Situations

• Health care providers, first responders have mandatory reporting obligations
• Obligations vary depending on the state from abuse to child birth and beyond.
• Child abuse
• Older person abuse
• Injury during comission or a felony
• Drug related injuries
• Child birth
• Sucides
• Certain communicable conditions
• Assault
• Exposures to infectious dieases
• Scene of crime

Ethical Responsibilities

• EMT needs to have ethical obligations to themselves, coworkers, public, and patient.
• Ethics is the philosophy of right and wrong
• Morality is code of conduct
• Bioethics directly addresses ethical issues of health care
• Ethical standards need to be placed in a situation according to Own & Professions guidelines.
• Applied ethics is where principles ethics get incorporated to one's conduct

The EMT in Court

• EMT could be subpoenaed as witness or defendant
• Case may be civil or criminal
• To Testify: -Contact director and legal counsel before court to give neutral account -Before the case review run report ahead of time
• Attorney should be able to defend EMT
• Attorney gets retained during civil suit

Potential Defenses

• Statute of limitations (the time within which a case must be commenced)
• Governmental Immunity (municipalities and other government entities)
• Contributory Negligence (defendant sues for damages patient suffered)
• Discovery (both sides obtain more information) (interrogatories, depositions)
• Most cases are settled and that can't be done a trial will be used
• Compensation for sustained injuries for plaintiff.
• Punative damages and a reckless disregard for safety.