Topic OverviewTopic Overview
Standard of care / Scope of practiceStandard of care / Scope of practice ConsentConsent
Informed (Expressed)Informed (Expressed) ImpliedImplied Children and mentally Incompetent Children and mentally Incompetent
AdultsAdults Refusal of CareRefusal of Care Advanced DirectivesAdvanced Directives
Do Not Resuscitate (DNR) orders Do Not Resuscitate (DNR) orders Living wills.Living wills.
ObjectivesObjectives
NegligenceNegligence DutyDuty
Legal vs. moralLegal vs. moral Breach of DutyBreach of Duty
AbandonmentAbandonment Battery Battery
CausationCausation DamagesDamages
Good Samaritan LawsGood Samaritan Laws ConfidentialityConfidentiality Crime scene preservationCrime scene preservation DocumentationDocumentation
Legal and Ethical Legal and Ethical ConsiderationsConsiderations
Legal DutiesLegal Duties All states have established guidelines to All states have established guidelines to
allow emergency care to be given allow emergency care to be given without worry of being sued.without worry of being sued.
Laws require a certain “Standard of Care”Laws require a certain “Standard of Care” Standard of Care Standard of Care
Care expected based on the provider’s Care expected based on the provider’s training and experience, taking into account training and experience, taking into account the conditions under which the care is the conditions under which the care is rendered.rendered.
Legal and Ethical Legal and Ethical ConsiderationsConsiderations
Based on laws, administrative orders and Based on laws, administrative orders and guidelines published by the EMS system, guidelines published by the EMS system, organizations and societies.organizations and societies.
First Responder guidelines established byFirst Responder guidelines established by USDOTUSDOT StateState Institutional (PCC and CCE)Institutional (PCC and CCE)
Legal and Ethical Legal and Ethical ConsiderationsConsiderations
Ethical ResponsibilitiesEthical Responsibilities Primary ConsiderationPrimary Consideration
Make the physical and emotional needs of the patient a Make the physical and emotional needs of the patient a prioritypriority
Additional ResponsibilitiesAdditional Responsibilities Maintaining skills and knowledgeMaintaining skills and knowledge
Includes practicing until you have obtained confidence and Includes practicing until you have obtained confidence and mastery of the skillsmastery of the skills
Continuing education and refresher programsContinuing education and refresher programs Review your performance and assess the techniques you Review your performance and assess the techniques you
useuse Evaluate yourselfEvaluate yourself Be honest in reporting care providedBe honest in reporting care provided
Legal and Ethical Legal and Ethical ConsiderationsConsiderations
ConsentConsent ConsentConsent
Patient says or acknowledges that Patient says or acknowledges that you can treat themyou can treat them
Expressed Consent Expressed Consent Consent given by a rational adult after Consent given by a rational adult after
being informed of the provider’s training being informed of the provider’s training and what care procedures are to be done. and what care procedures are to be done. Risks and options to care.Risks and options to care.
Legal and Ethical Legal and Ethical ConsiderationsConsiderations
Implied ConsentImplied Consent An unconscious patient is assumed to want help.An unconscious patient is assumed to want help.
A legal position that assumes an unconscious or badly A legal position that assumes an unconscious or badly injured adult patient would consent to receiving injured adult patient would consent to receiving emergency care.emergency care.
May apply to other type of patients as wellMay apply to other type of patients as well Mentally illMentally ill
Children and Mentally Incompetent AdultsChildren and Mentally Incompetent Adults Parental ConsentParental Consent Serious Injury/Illness in the absence of a parentSerious Injury/Illness in the absence of a parent
A form of implied consentA form of implied consent
Legal and Ethical Legal and Ethical ConsiderationsConsiderations
CompetenceCompetence The patient’s ability to understand your The patient’s ability to understand your
questions.questions. The patient’s ability to understand the The patient’s ability to understand the
implications of decisions made.implications of decisions made. Not competent when:Not competent when:
intoxicatedintoxicated drug ingestiondrug ingestion serious injuryserious injury mental incompetencemental incompetence
Legal and Ethical IssuesLegal and Ethical Issues To determine competenceTo determine competence
Ask QuestionsAsk Questions PPTEPPTE WWWWHWWWWH
Remember answering questions does not always Remember answering questions does not always establish competence - Suicidalestablish competence - Suicidal
Legal and Ethical Legal and Ethical ConsiderationsConsiderations
Refusal of CareRefusal of Care When conscious and competent patients can When conscious and competent patients can
refuse your carerefuse your care Reasons may be based onReasons may be based on
religious groundsreligious grounds lack of trustlack of trust personal reasonspersonal reasons
You CAN NOT force care on these patientsYou CAN NOT force care on these patients You CAN NOT legally restrain them until EMS You CAN NOT legally restrain them until EMS
arrivesarrives
Legal and Ethical Legal and Ethical ConsiderationsConsiderations
Only Course of ActionOnly Course of Action Try to gain their confidence through conversationTry to gain their confidence through conversation When your services are refused:When your services are refused:
Do Not argueDo Not argue Do Not question their reasons (if based on religious Do Not question their reasons (if based on religious
views)views) Do Not touchDo Not touch Stay Calm and ProfessionalStay Calm and Professional Make sure EMS has been activatedMake sure EMS has been activated Talk to the patientTalk to the patient If possible have a neutral witness to your offer to helpIf possible have a neutral witness to your offer to help
Legal and Ethical Legal and Ethical ConsiderationsConsiderations
If a patient is not competent they cannot refuse If a patient is not competent they cannot refuse medical care or give consentmedical care or give consent
Often times this is where law enforcement becomes Often times this is where law enforcement becomes involved i.e...mental warrantinvolved i.e...mental warrant
A parent or guardian can refuse to let you care for a A parent or guardian can refuse to let you care for a childchild
Follow the previously discussed steps.Follow the previously discussed steps. IF an adult takes a child from the scene before IF an adult takes a child from the scene before
EMS arrives, you must report the incident to EMS EMS arrives, you must report the incident to EMS or the policeor the police
Conscious patient refuses care then becomes Conscious patient refuses care then becomes unconscious, implied consent usually takes over unconscious, implied consent usually takes over and care beginsand care begins
Legal and Ethical Legal and Ethical ConsiderationsConsiderations
Advance DirectivesAdvance Directives DNR (Do Not Resuscitate) OrdersDNR (Do Not Resuscitate) Orders
Legal documentLegal document Signed by physician and patientSigned by physician and patient Terminal illness & does not wish to prolong life Terminal illness & does not wish to prolong life
through resuscitative effortsthrough resuscitative efforts Texas has a state wide form that must be usedTexas has a state wide form that must be used The Original DNR form or a copy of the form The Original DNR form or a copy of the form
are to be accepted (NEW)are to be accepted (NEW) Approved ID bracelet with patient information Approved ID bracelet with patient information
engravedengraved
Legal and Ethical Legal and Ethical ConsiderationsConsiderations
Living WillsLiving Wills Document signed by patient regarding use Document signed by patient regarding use
of long-term life support and comfort of long-term life support and comfort measures such as respirators, intravenous measures such as respirators, intravenous feedings, pain medications.feedings, pain medications.
Legal and Ethical Legal and Ethical ConsiderationsConsiderations
NegligenceNegligence Basis for most lawsuits involving Basis for most lawsuits involving
prehospital care is negligenceprehospital care is negligence You could be sued IF:You could be sued IF:
You had a Duty to Provide care or you You had a Duty to Provide care or you assume the responsibility to provide careassume the responsibility to provide care
Care for the patient was not provided to the Care for the patient was not provided to the “standard of care”“standard of care”
Patient was injured in some way as a result Patient was injured in some way as a result of this improper careof this improper care
Legal and Ethical Legal and Ethical ConsiderationsConsiderations
Duty to ActDuty to Act While on duty a first responder has a While on duty a first responder has a
obligation to respond to an emergency and obligation to respond to an emergency and provide care at the sceneprovide care at the scene
Your duty to act may involve your officeYour duty to act may involve your office If you volunteer for an organization, you have a If you volunteer for an organization, you have a
duty to act within the respond area of that duty to act within the respond area of that organization organization
As a Doctor of Chiropractic?????As a Doctor of Chiropractic?????
Breach of DutyBreach of Duty Substandard care or care given beyond your Substandard care or care given beyond your
level of traininglevel of training
Legal and Ethical Legal and Ethical ConsiderationsConsiderations
Assault / BatteryAssault / Battery Not a universal definitionNot a universal definition
Unlawful touching of a victim without their Unlawful touching of a victim without their consentconsent
Providing care when a competent patient Providing care when a competent patient refuses carerefuses care
Legal ConsiderationsLegal Considerations
In Texas an assault is comparable In Texas an assault is comparable crime under the Texas Penal Codes.crime under the Texas Penal Codes.
CHAPTER 22. ASSAULTIVE OFFENSESCHAPTER 22. ASSAULTIVE OFFENSES Sec. 22.01. Assault.Sec. 22.01. Assault.
(a) A person commits an offense if the person:(a) A person commits an offense if the person: (b) intentionally or knowingly causes physical (b) intentionally or knowingly causes physical
contact with another when the person knows or contact with another when the person knows or should reasonably believe that the other will should reasonably believe that the other will regard the contact as offensive or provocative.regard the contact as offensive or provocative.
(c) An offense under Subsection (a)(2) or (3) is a (c) An offense under Subsection (a)(2) or (3) is a Class C misdemeanor, except that an offense Class C misdemeanor, except that an offense under Subsection (a)(3) is a Class A misdemeanor under Subsection (a)(3) is a Class A misdemeanor if the offense was committed against an elderly if the offense was committed against an elderly individual or disabled individual, as those terms individual or disabled individual, as those terms are defined by Section 22.04.are defined by Section 22.04.
Legal and Ethical Legal and Ethical ConsiderationsConsiderations
CauseCause If duty and breach of duty are established, If duty and breach of duty are established,
negligence may be proven if the action or negligence may be proven if the action or lack of action caused injury (damage) in lack of action caused injury (damage) in some form due directly to your actions.some form due directly to your actions.
DamageDamage Physical damagePhysical damage
Moving a patient before a fractured leg is Moving a patient before a fractured leg is splinted.splinted.
Legal and Ethical Legal and Ethical ConsiderationsConsiderations
Emotional or PsychologicalEmotional or Psychological Inappropriate care does not always involve a Inappropriate care does not always involve a
physical skill, it could be you tell someone they physical skill, it could be you tell someone they don’t need emergency care when they do so EMS don’t need emergency care when they do so EMS is delayed and the delay caused complicationsis delayed and the delay caused complications
Good Samaritan LawsGood Samaritan Laws Grant immunity from civil liability if:Grant immunity from civil liability if:
you acted in good faithyou acted in good faith you provided care to the best of your abilityyou provided care to the best of your ability
Legal and Ethical Legal and Ethical ConsiderationsConsiderations
AbandonmentAbandonment Once you stop to help you have legally Once you stop to help you have legally
begun carebegun care Once you start you have assumed a duty Once you start you have assumed a duty
to continue untilto continue until patient is turned over to more advanced patient is turned over to more advanced
medical personnel (EMS)medical personnel (EMS) You have abandoned the patient if:You have abandoned the patient if:
you leave before EMS or a person with you leave before EMS or a person with higher training arrives and takes overhigher training arrives and takes over
includes the failure to turn over patient includes the failure to turn over patient information during the transfer to more information during the transfer to more highly trained personnelhighly trained personnel
Legal and Ethical Legal and Ethical ConsiderationsConsiderations
Confidentiality Confidentiality Confidential InformationConfidential Information
history, gained through interviewhistory, gained through interview assessment findingsassessment findings emergency care renderedemergency care rendered
Releasing Confidential InformationReleasing Confidential Information Required written release from the patientRequired written release from the patient Not required when EMS personnel need information Not required when EMS personnel need information
to continue careto continue care SubpoenaSubpoena
Legal and Ethical Legal and Ethical ConsiderationsConsiderations
Reportable EventsReportable Events Include:Include:
exposure to blood and OPIMexposure to blood and OPIM certain infectious diseasescertain infectious diseases vehicle accidentsvehicle accidents drug-related injuriesdrug-related injuries crimes resulting in knife or gunshot woundscrimes resulting in knife or gunshot wounds child and elder abusechild and elder abuse domestic violencedomestic violence raperape
Legal and Ethical Legal and Ethical ConsiderationsConsiderations
Special SituationsSpecial Situations Organ DonorsOrgan Donors
Emergency care must not differEmergency care must not differ All emergency care measures must be taken All emergency care measures must be taken
including CPRincluding CPR Medical Identification DevicesMedical Identification Devices
Look for a necklace, bracelet, ankle bracelet, Look for a necklace, bracelet, ankle bracelet, cardcard
Legal and Ethical Legal and Ethical ConsiderationsConsiderations
Crime ScenesCrime Scenes Evidence PreservationEvidence Preservation
Don’t move anything Don’t move anything unless care absolutely requires itunless care absolutely requires it
Note position of the weapon if movedNote position of the weapon if moved Note the position of the patientNote the position of the patient Do not cut where the stab or gunshot wound cut Do not cut where the stab or gunshot wound cut
the clothingthe clothing
Scene should not be entered until it is Scene should not be entered until it is secure.secure.
Legal ConsiderationsLegal Considerations
DocumentationDocumentation If you do not write it down, a court of law If you do not write it down, a court of law
would say it did not happen!would say it did not happen! If paperwork to is sloppy and unreadable, If paperwork to is sloppy and unreadable,
a court of law would say care was also a court of law would say care was also sloppysloppy