Chapter 3

Medical, Legal, and Ethical Issues

 Key Terms

Abandonment In loco parentis

Advance Directive Liability
Assault Libel
Battery Moral
Confidentiality Negligence
Consent Organ Donor
Crime Scene Physician Orders for Life-Sustaining Treatment
Do Not Resuscitate Order (DNR) (POLST)
Duty to Act Res ipsa loquitor
Ethical “Safe Haven” Law
Expressed Consent Scope of Practice
Good Samaritan Laws Slander
HIPAA Standard of Care
Implied Consent Torte
 Some examples:
Making sure the patient accepts help
Terminally ill patient refuses all care
Should you stop and render aid even
Every time you though you are not on duty?
respond to a call, you Can you get sued if you stop and
will be faced with render aid if it is outside your
some aspect of ambulance district?
medical/legal or
medical/ethical issues.
 Scope of Practice

Scope of Practice: Defines the extent and limits of an EMT’s job. The EMT’s skills and medical interventions
they may perform. Are defined by legislature and vary from state to state. What you should be able to do.
Your duty is to provide for the well-being of the patient by rendering necessary and legally allowed care as
defined by the scope of practice in your area.
Primary ethical considerations under your scope of practice:
-Making patient care and well-being a priority, even if this means making some personal sacrifices. (Turning
the heat on for a patient who is cold even when it is hot outside)
Standard of Care: The care that would be expected to be provided by an EMT with similar training when
caring for a patient in a similar situation. What you should do in a particular situation and how you should
do it.
Emergency Medical Care:
Immediate care or
treatment
Providing competent
emergency care that
conforms to the scope
and standard of care
will help you avoid both
civil and criminal
actions.
Even when emergency
care is properly
rendered, there are
still times when you
may be sued by a
patient who seeks
compensation.
Administrative actions,
such as suspension of
your state EMT license,
may be brought against
you for failure to abide
by the regulations of
your state EMS agency.
Decision Making
Capacity: Ability to
understand and process
 Consent: Permission from the patient to have you
treat them. You must have expressed consent from
every conscious, mentally competent adult before
providing care and transportation.
Patient Consent
and Refusal Expressed Consent: Consent given by adults who
are of legal age and mentally competent to make a
rational decision with regards to their medical well-
being, must be obtained from ALL patients who are
physically and mentally able to give it.

INFORMED CONSENT: Patients must

understand all of the risks associated with the care
they will receive. It is not only a legal requirement
but also appropriate emotional care to explain all
procedures to the patient.
 Implied Consent: Assumed consent for a patient that is unconscious, physically unable, mentally unable to give
consent.
Emergency Doctrine: The principle of law that permits a health care provider to treat a
patient in an emergency situation when the patient is incapable of granting consent because
of AMS, altered level of consciousness, disability, effects of drugs or alcohol.
Medicolegal: Term relating to medical jurisprudence (Law) or forensic medicine.
 Children and incompetent adults are legally NOT allowed to
consent or refuse medical care or transportation.
Children and - The parents and guardians of these patients have the legal
authority to give consent, so it must be obtained before care can
be given.
Mentally - There are times when care may be given without direct
consent from the parent or guardian.

Incompetent Example: School official or a child care provider acts in loco

parentis.

Adults In loco parentis: In place of a parent (When the parents not

physically present)
Implied Consent: Law provides that it is reasonable to believe
that a responsible parent or guardian would consent to care if they
were present in life-threatening situations.
Emancipated minors (those who are married or of certain age,
usually 16 or older and declared independent of their parents)
are allowed to give consent.
 Involuntary Transportation:
Some patients will have to go to the hospital involuntarily (against their will).
- May be the result of a decision the police, or mental health workers when they believe a patient poses a
threat of harm to themselves or others (psychiatric patients).
- Patients may be forced to go to the hospital based on a court order.
You may have to physically restrain a patient during transport.
- When you deny a patient the freedom of moving, you have to ensure the patient’s health and well-being
during that time. Many lawsuits are brought against EMS for improper restraining or harm caused to the patient
during restraint or transport.
- It is essential you monitor the patient’s vitals and mental status while they are in your care.
RIGHT WRONG
WAY WAY
 Several conditions must be met:
Patient Refusal

1. Patients must be legally able to consent (of legal age or emancipated minor)
2. Patients must be awake and oriented (Must be conscious, alert, and oriented)
3. Patients must be fully informed (Must be informed of their situation and understand the risks of refusing care)
4. Patients will be asked to sign a “release” form (designed to release the agency and individuals from liability or
legal responsibility) that comes from the patients informed refusal)
Even following those steps cannot guarantee you will be free from liability if you leave a patient after they refuse care
or transport and deteriorate.
You also have ethical issues in addition to liability issues. You will feel guilty if the patient dies after refusing care that
you deemed necessary.
Actions you should take to try to persuade a patient to be transported:
Spend time speaking with the patient.
Listen carefully to try to determine why the patient is refusing care.
Inform the patient of the consequences of not going to the hospital. This is an
essential component of every refusal-of-care situation.
Consult Medical Direction.
Ask the patient if it is ok if you call one of their family members or advise the
patient that you would like to call a family member.
**DO NOT DO THIS AGAINST THEIR WISHES! THAT IS A HIPAA
VIOLATION**
6. Call law enforcement personnel if necessary.
7. Ask the patient to sign the refusal of care form used by your agency.
You do not have the right to force the patient to go to the
hospital against their will. THIS IS KIDNAPPING.
Subjecting patients to unwanted care and transported has
been viewed in court as:
Assault – Putting a person in fear of bodily harm.
Battery – Causing said harm or restraining.
If a patient still refuses care and/or transport, it is extremely
important to fully document all efforts/attempts you made
to try to convince the patient to go to the hospital. This will
help prevent liability.
Always remember to advise a patient who has refused
care/transport that they can always call back if they change
their mind or the problem worsens.
CONFIDENTIALITY
Communication between you and your patient CANNOT be disclosed without permission from the patient or court
order except to those providers directly involved in the care of the patient (ER Dr, ER RNs, ALS intercepts)
Confidential information includes patient hx, assessment findings, and treatment provided.
Breach of Confidentiality: Disclosure of information without proper authorization.
Health Insurance Portable and Accountability Act of 1996 (HIPAA)
The section that affects EMS relates to patient privacy
The aim of this section of the act is to strengthen laws for the protection of the privacy health care information and to
safeguard patient confidentiality.
It provides guidance on what types of information is protected, the responsibility of the health care providers
regarding that protection, and the penalties for breaching that protection.
HIPAA considers all patient information that you obtain in the course of providing medical treatment to the patient to
be protected health information.
Protected Health Information (PHI): Any information about health status, provision of health care, or payment for health
care that can be linked to an individual. This is interpreted broadly and includes ANY part of a patients medical record or
payment history.
You are permitted to report your assessment findings and treatment to other health care providers directly involved in
the care of the patient; internal QA/QI programs; or you may be legally mandated to report your findings such as in
cases of child abuse or your receive a subpoena.
Social Media
Sharing personal opinions about work and non-work related topics via social media is typically not approved of even if
it is off duty and on your personal devices.
Most departments have a designated spokesperson and publicist to handle all things media related.
Do Not DNR- Do Not Resuscitate, legal document signed by the
patient and their physician stating does not wish to prolong
life through resuscitative measures, usually they are
Resuscitate terminally ill.
- May be part of an advanced directive, written and signed
Orders and in advance of any event where resuscitation might be
undertaken.
Physician’s It may also be part of a Physician’s Orders for Life-
Sustaining Treatment (POLST), this also usually includes
Orders for if the patient wishes to be on mechanical ventilation, fed
through a feeding tube, or antibiotics used. POLST’s are
Life- usually found in Nursing Homes and Rehabs.
A legal DNR order prevents unwanted resuscitation. You
Sustaining must follow DNR orders. If the family asks you to go against
DNR orders, call Medical Control for advice and to speak to
Treatment the family.
IF YOU DO NOT HAVE THE PHYSICAL DNR, YOU MUST
(POLST) RENDER AID!
Durable Power of Attorney for Health Care (POA): A type of advance directive executed by a
competent adult that appoints another individual to make medical treatment decisions on his
or her behalf, in the event that the person making the appointment loses decision-making
capacity.
Health Care Proxy: A type of advance directive executed by a competent adult that appoints
another individual to make medical treatment decisions on his or her behalf in the event that
the person making the appointment loses decision-making capacity (also known as POA)
When presented with a POA at the scene, you MUST read it carefully to ascertain its
meaning and validity.
If there is any question, you should contact OLMC for assistance.
Do NOT delay emergency care while efforts to interpret the POA are made.
A patient who is conscious and competent does not surrender the rights to make medical
decisions. POA only takes affect when the patient is not conscious, not competent, or is
AMS
Remember, a DNR does not mean do not render care! You are still obligated to
provide supportive comfort measures to those who are not in cardiac arrest.
Negligence Negligence: Something that should have been done was not
done or was done incorrectly.
Finding negligence, or failure to act properly, requires that
ALL of the following circumstance be proved:
The EMT had a duty to the patient.(duty to act)
The EMT did not provide the standard of care. (committed
breach of duty)
There was a proximate causation (the concept that the
damages to the patient were the result of action or inaction
of the EMT)
The concept used in tort law is res ipsa loquitur (the thing
speaks for itself). This is the foundation in negligence
because it allows a finding of negligence even when there is
no evidence of a negligent act.
Physical Signs of Death
Determining cause of death is the medical examiners job, not yours.
There are definitive and presumptive signs of death.
Death: Is defined as the absence of circulatory and respiratory function; irreversible cessation of all functions of the
brain and brainstem.
If the body is still in tact and there are no definitive signs of death, initiate resuscitative measures.
Presumptive Signs of Death
Unresponsive to painful stimuli
Lack of carotid pulse or heartbeat
Absence of chest rise and fall
Absence of pupillary reactivity (pupils are fixed and dilated)
No blood pressure
Profound cyanosis
Lowered or decreased body temperature
Definitive Signs of Death
Obvious mortal damage, such as decapitation
Dependent Lividity: Blood settling (pooling) to the lowest point of the body causing discoloration of the skin
Rigor Mortis: Stiffening of the body muscles caused by chemical changes within muscle tissues. Develops first in the
face and jaw, gradually extending downward until the body is in full rigor. Typically occurs within 3 hours after person
dies and can take up to 12 hours to be in full rigor mortis.
Algor Mortis: Refers to the cooling of the body until it matches ambient air temperature
Putrefaction: Decomposition of body tissues. Depending on temperature conditions, occurs between 40 - 96 hours
after death. The hotter it is, the faster it occurs.
Medical Examiner Cases
It varies from state to state and depends on the nature and scene of the death.
Typically when trauma is a factor or death involves suspected criminal or unusual situations
such as hanging or poisoning, the ME must be notified. In Maine, Law Enforcement will
notify the ME.
Examples of when ME is called:
Unattended death (patient dies at home and not in presence of an MD so cause us unable to
be stated if not obvious (heart attack in sleep, massive stroke, etc)
Suicide
Violent death
Poisoning or suspected poisoning
Death resulting from unintentional injuries
Suspicion of a criminal act
Infant and child deaths
ALWAYS LIMIT DISTURBANCE OF A SCENE AT AN UNATTENDED DEATH OR CRIMINAL DEATH.
SCENE PRESERVATION IS CRUCIAL!
Keep thorough notes of what was done and seen
You may have to cover the body. Use a tarp and not a sheet to prevent evidence from being
transferred off of the body
Special Situations
Organ Donors
you may be called to the scene involving a potential organ donor.
This may require you to consult with OLMC when faced with this
situation (is very rare to happen)
Medical Identification Insignia
Many patients carry important medical identification and information.
This may be in the form of a bracelet, necklace, key chain, or a card
that IDs patient hx information.
May include a DNR or information related to medications taken,
allergies, diabetes, epilepsy, or some other serious condition.
Some necklaces and bracelets now contain USB flash drives with all of
the patients pertinent information.
Defamation
Defamation: The communication of false information about a person that is damaging to that person’s reputation
or standing in the community
Libel: False and damaging information about a person that is communicated in writing
Slander: False and damaging information about a person that is communicated by spoken word.
A legal claim for defamation could Arie out of a false statement on a run report (it is a legal document),
inappropriate comments made on social media or during “In house” conversations at the station sharing war
stories.
Good Samaritan laws and immunity
Good Samaritan law: Statutory provision enacted by many states to protect citizens from liability for errors and
omissions in giving good-faith emergency medical care, unless there is wanton, gross, or willful negligence
Gross Negligence: Conduct that constitutes a willful or reckless disregard for a duty or standard of care
Special Mandatory Reporting Requirements:
Abuse of Children, Older People, and Others
Injury During the Commission of a Felony
Drug-Related Injuries
Childbirth
Other Reporting Requirements
Burns (children under a certain age)
Attempted suicide
Dog bites
Certain Communicable Diseases
Assaults
Domestic Violence
Sexual Assault
Rape
CRIME SCENES
AGAIN DO NOT DISTURB EVIDENCE AT A CRIME SCENE! Try to leave everything where it is as
you found it. If you must move something, like a knife or handgun, document where you found it
and where you moved it to in your report and report it to the police so they can document it as
well.
- If it is a sexual assault, do not let the patient shower, cleanse themselves, or wash their hands.
Have them change into scrubs and place the original clothing, including undergarments, into a
paper bag.
Ethical Responsibilities
Ethics: The philosophy of right and wrong, of moral duties, and of ideal professional
behavior
Morality: Code of conduct that can be defined by society, religion or a person,
affecting character, conduct and conscience
Bioethics: Study of ethics related to issues that arise in health care
Applied Ethics: The manner in which principles of ethics are incorporated into
professional conduct.
- Your behavior both on and off the job is a reflection of your personal ethical
standards.
The EMT in Court
There are several different circumstances that might cause you to end up in court, either as a witness or defendant in
a civil lawsuit or defendant in a criminal case.
Whenever you subpoenaed to testify, you have to notify your service director and legal counsel.
As a witness, always remain neutral on the stand during testimony
Statute of Limitations: The time within which a legal case must be commenced.
Governmental Immunity: Legal doctrine that can protect an EMS provider from being sued or that may limit the amount
of the monetary judgement that the plaintiff may recover; generally applies only to EMS systems that are operated by
municipalities or other governmental entities.
Contributory Negligence: A legal defense that may be raised when the defendant thinks that the conduct of the plaintiff
somehow contributed to any injuries or damages that were sustained by the plaintiff
Discover: The phase of a civil lawsuit where the plaintiff and defense obtain information from each other that will
enable to attorneys to have a better understanding of the case and which will assist in negotiating a possible
settlement or in preparing for trial. Discovery includes depositions, interrogations, demands for production of records.
Interrogatories: Written questions that the defense and plaintiff send to one another.
Depositions: Oral questions asked of parties and witnesses under oath.
Compensatory Damages: Damages awarded in a civil lawsuit that are intended to restore the plaintiff to the same
condition that they were in prior to the incident
Punitive Damages: Damages that are sometimes awarded in a civil lawsuit when the conduct of the defendant was
intentional or constituted a reckless disregard for the safety of the public