Emergency Care: Core Principles and Consent

Core Principles

• A basic tenet of emergency care is to do no further harm.
• Competent care within your scope of practice, adhering to the standard of care, helps avoid legal issues.
• Lawsuits can occur even if care is properly administered.

Consent

• Permission to provide care is required.
• A person must give consent for treatment.
• A conscious, rational patient can refuse care.
• Decision-making capacity is foundational to consent.
• Patients have a right to make their own healthcare decisions which is known as patient autonomy.
• Factors impacting decision-making capacity include intellectual ability, legal age, or impairment.

Types of Consent

• Expressed Consent: Patient acknowledges willingness to receive care or transport.
• Informed Consent: Requires explaining the treatment, risks, benefits, alternatives, and consequences of refusal.
• Implied Consent: Applies when patients are unconscious or unable to make rational decisions, used only when a serious medical condition poses a threat to life or limb.
• Known as the emergency doctrine, implied consent is when a relative or spouse should be consulted prior to treatment.
• Involuntary Consent: Applies to the mentally ill, those in behavioral crises, or the developmentally delayed; requires consent from a guardian or conservator.

Minors and Consent

• Generally, a parent or legal guardian gives consent for minors.
• An emancipated minor is an individual under the legal age who is legally considered an adult.
• Emancipated minors are those who are married, in the armed services, or living away from home and self-supporting.
• Teachers/officials can act in loco parentis in school/camp settings.
• Implied consent can be applied when there is a true emergency in the absence of a parent(s) or legal guardian.

Forcible Restraint

• Is permissible when a patient is a danger to themselves or others, and needs medical treatment and transport.
• Medical control authorization and law enforcement assistance is needed.
• Restraining without legal authority invites civil and criminal penalties.
• Local laws and protocols should be known/followed in regards to forcible restraint.
• Do not remove en route unless restraints endanger the patient.
• ALS backup can provide chemical restraint.

The Right to Refuse Treatment

• Conscious, alert adults with decision-making capacity can refuse treatment, with the result being possible death or serious injury.
• Refusal of treatment calls often lead to litigation; local protocols/policies must be adhered to.
• Consultation with medical control must occur and is needed for documention.
• Base treatment decisions of guardian/caregiver on information provided such as assessment results, necessary treatment details, risks, alternatives, refusal consequences.
• Assess and document the patient's ability to make an informed decision by asking/repeating questions, assessing answers, and observing behavior.
• Confused, delusional, or suicidal patients cannot make an informed refusal.

Action Tips for EMTs

• Providing treatment is more defensible than withholding it when in doubt and not endangering yourself.
• Encourage the patient/caregiver to permit treatment again before leaving the scene after refusal.
• Advise calling 9-1-1 if the patient changes their mind.
• Advise contacting a physician promptly.
• Request a signed refusal form.
• A witness should be present.
• Document all refusals thoroughly.

Confidentiality

• Communications between you and the patient is confidential.
• Confidential information consists of patient history, assessment findings, and treatment information.
• Releasing information inappropriately may be considered a breach of confidentiality, or disclosure without authorization.
• Records can be released if the patient signs a release, a legal subpoena is presented, or is needed by billing personnel.

HIPAA

• The Health Insurance Portability and Accountability Act of 1996 includes a section on patient privacy, strengthening privacy laws.
• HIPAA offers guidance on protected information types, provider responsibilities, and breach penalties.
• HIPAA regards all patient information you obtain as protected health information (PHI).
• PHI includes medical information and any data that can identify the patient.
• Civil or criminal action against you/your agency can be the result of failing to follow HIPAA rules.
• The public may record identifying/protected patient data and images when permitted by law.

Social Media

• Avoid logos, uniforms, vehicles, or associating marks with your agency while off duty, unless acting as an agency spokesperson.
• Maintain on-duty professionalism when off duty.
• Respect patients, bystanders, colleagues, and the organization you represent both online and in person.
• Freedom of speech isn't a right to say anything without repercussions.

Advance Directives

• Family may not want you to resuscitate a patient who is dying when you arrive.
• A do-not-resuscitate (DNR) order gives permission to withhold resuscitation.
• Does not mean "do not treat" as supportive measures (oxygen, pain relief, comfort) are still obligated for a patient in a cardiac arrest.
• Protocols need to be in place for each ambulance service in such circumstances.
• Advance directives are written documents specifying medical treatment for a competent patient in the event they cannot make decisions.
• This is most commonly used when a patient is comatose.
• They are often referred to as a living will or health care directive.

Legal Requirements for Valid DNR Orders

• A clear statement of the patient's medical problem(s).
• Signature of the patient or legal guardian.
• Signature of one or more physicians or other licensed health care providers.
• DNR orders with expiration dates must be dated in the preceding 12 months to be valid.
• In terminal care facilities often POLST or MOLST medical orders describe acceptable interventions, which is required to be signed by an authorized medical provider.
• Contact medical control for guidance when these documents are encountered.
• Some patients may have named surrogates to make decisions for them when they can no longer do so.
• These are called durable powers of attorney for healthcare or health care proxies.

Physical Signs of Death

• A physician is responsible for determining the cause of death.
• Presumptive signs of death: Unresponsiveness to pain, lack of pulse/heartbeat, no chest rise/fall, no reflexes, no pupillary reactivity, no blood pressure, profound cyanosis, lowered body temperature.
• Definitive signs of death: Obvious mortal injury, dependent lividity (blood settling), rigor mortis (stiffening), algor mortis (cooling).
• Putrefaction occurs between 40 and 96 hours post mortem as bodily tissues decompose.

Medical Examiner Cases

• The medical examiner's involvement depends on the death's nature and scene.
• The coroner or medical examiner must be notified when someone is DOA, or there is death without previous medical care, a suicide, suspected poisoning, violent death, an accident, suspicious of a criminal act, and infant or child deaths.
• Disturb the scene as little as possible.
• Document emergency medical care and scene findings carefully when care has been initiated .

Special Situations

• Organ donors have the wish to donate their organs and their consent is evidenced by information on a donor card or driver's license.
• Prioritize saving the patient's life while remembering the organs require oxygen.
• Medical identification insignias include bracelets, necklaces, keychains, or cards that indicate allergies, or other serious medical condition.
• USB medical bracelets often store data as PDFs.

Scope of Practice

• Outlines the care you're able to provide and is defined at the state level.
• A medical director refines it further via protocols/standing orders.
• The medical director authorizes care through telephone/radio (online) or standing orders/protocols (offline).
• Exceeding scope may be considered negligence.

Standards of Care

• The way one must act/behave is called a standard of care.
• How someone with similar training would act in similar situations, with how the standard of care is defined.
• The standard of care is established by local custom, imposed by law, professional/institutional benchmarks, textbooks, and states.

Duty to Act

• An individual's responsibility to provide patient care.
• A legal duty exists once an ambulance responds to a call.
• Off-duty EMTs usually aren't legally bound to help at a crash scene.
• Knowledge of local laws and protocols is key in determining ones duty to act.

Negligence

• Negligence- failure to provide the same care that someone with similar training would.
• All four must be present for the legal doctrine of negligence to apply:.
• Duty: The obligation to provide care within training/protocols.
• Breach of duty from an EMT who didn't act within the expected/reasonable care standard.
• Damages: A patient is physically or psychologically harmed in some way.
• Causation: A cause-and-effect from a breach of duty that results in damages to the patient.
• Res ipsa loquitur arises when it is shown the injury was caused by the EMT and the negligence.

Negligence Per Se & Torts

• Arises when a statute occurs because of a clear violation.
• An EMT performing an ALS skill that is the reason for a patients injury is one example.
• Civil wrongs outside US criminal courts include defamation and privacy invasion.

Abandonment

• Abandonment: When the EMT unilaterally terminates care without the patient's consent, without arranging for further medical attention.
• The EMT has a duty to act until a more qualified provider assumes responsibility once care has started.
• Can occur when the patient is dropped off at the scene or in the emergency department where you are dropping off your patient.
• Obtain a signature on the patient care report from the person accepting transfer of care at the hospital.

Assault, Battery and Kidnapping

• Assault is unlawfully causing fear of bodily hard.
• Battery is unlawfully touching a person without the patient's consent.
• Includes threatening to restrain a patient who does not want to be transported.
• Kidnapping involves restriction of movement against someones will.
• This can include transporting a patient against their will and can include false imprisonment.
• Legal problems may arise when consent is not clear.

Defamation

• Defamation is communicating false information that damages reputation.
• Libel (written)
• Slander (spoken)
• Statements on run reports must be accurate, factual, & relevant.

Good Samaritan Laws and Immunity

• The common law principle that allows individuals that help reasonably to not be held reliable for damages.
• To be protected by provisions of Good Samaritan law, several conditions must generally be met:
  • Act in good faith.
  • Render care without expectation of compensation.
  • Do not exceed your scope of practice.
  • Do not act in a grossly negligent manner.
• Gross negligence is a reckless disregard for a duty or standard of care.
• Limitations on liability that EMS systems have are provided by Immunity statutes for those that are a governmental agency.

Records and Reports

• To safeguard legal complications agencies must mainatin good records of patients interactions (sick or injured).
• Courts view them as essential for recalling ones duty of care and a accurate representation of treatment.
• A procedure that is not written was not done.
• Untidy or incomplete is evidence of inexpert care.
• National EMS Information System (NEMSIS) permits the storage, standardization, and sharing of data throughout the United States.

Mandatory Reporting

• EMTs and health providers must report obligations in most states.
• Special reporting requirements may include:
  • All forms of abuse.
  • Felonies, drug related injuries, and childbirth injuries.
  • Attempted suicides or certain deaths.
  • Communicable diseases, dog bites, or crimes of any kind.
  • Exposure concerns for all kinds of communicable diseases.

Ethical Responsibilities

• In addition to legal duties, EMTs have ethical responsibilities to themselves, coworkers, the public, and the patient.
• Ethics is the philosophy of right and wrong and involves moral duties, and ideal behavior.
• Morality is the code of conduct affecting character, conduct, and conscience.
• Bioethics addresses ethical issues in health care.
• One must evalutate application to their own and professional standards.

The EMT in Court

• EMTs often enter as a witness or defendant in civil or criminal cases.
• You should alert management when receiving any subpoenas that you will be testifying in court.
• Always review past case reports and remain neutral.
• An attorney is require, usually supplied.
• Statues apply to cases that must commence within a specific time and also affect what amount of money can be rewarded.
• Discovery involves the opportunity for both sides to obtain more information to reach a better understanding of the case.
• The discovery phase is usually when cases are settled.
• Rewards provided are compensatory for damages or injuries etc and the punitive to warn against continuing the harmful behavior.