Legal Aspects of Medical Care Laws applicable to Medical Care

1. LEGAL ASPECTS
OF Medical Care
Prof. Syed Amin Tabish
FRCP (London), FRCP (Edin.), FACP, FAMS, MHA (AIIMS)
Postdoc Fellowship, Bristol University (England)
Doctorate in Educational Leadership (USA)

2. Legal Aspects of Medical
Practice
• With knowledge explosion and
technological advances mainly
aimed to provide high quality
medical care to individual
patients, the need for a careful
construction of a professional
ethics is urgent.
• Citizen’s charter on Health
Services
• Consumer Protection Act

3. Why Ethics
•Patients are
increasingly aware of
what they believe to be
their human rights &
expect doctors to
respect them

4. The Duties of Clinical Care
Rights of patients may be
summarized by 3
corresponding duties of
care which apply to all
patients:
- Protect life & health
- Respect Autonomy
- Fairness & justice

5. 1. The Duties of Clinical care
•Protect Life & Health
(clinicians to practice
medicine to high
standard not to cause
unnecessary
harm/suffering)

6. 2. The Duties of Clinical Care
Respect Autonomy:
• Humans have autonomy – the
ability to reason, plan and make
choices about the future
• Doctors are required to respect
these attributes (respect for the
dignity):
- informed consent
- confidentiality (per info)
Denying pts. such choice & control
robs them of their human dignity

7. 3. Fairness & justice
• The access to & quality of clinical care
should be need-based rather than
favoritism
• Injustice can occur through treating
patients unequally according to:
- socioeconomic status
- physical attraction
- profession
- age
- race
Equal Access to appropriate care
according to NEED

8. Why should Doctors take these
duties seriously?
• Professional regulation (Medical
Council)
• The Law (duties are also enshrined
in the constitution/statue/common
law)
- Doctors may be sued in Civil
Law for financial compensation for
any harm (failure in professional
duty)
- If this harm is intentional:
Criminal Law will apply

9. Why should Doctors take these
duties seriously?
• Rational Self-interest: support
the right of all patients to high
standard of care
• The clinical importance of trust:
lack of trust will spoil the quality
of pt. care & professional life
• The Doctor-Patient Relationship:
treat pts. As active partners in
healing process; Problem-solving
is by doctors; Decision-making is
by both (Doctor & Patient)

10. Medical Mistakes
Clinical Negligence
• Patient must provide
evidence to the Court that:
- they were harmed
- the harm was caused by
the accused doctor
- the action that causes the
harm was a breach of
professional duty

11. Challenges
• Consent
• Medical negligence
• Medical reports
• Certificates
• Sexual offenses
• Confidentiality
• Terminal illness
• Withdrawing of life-support

12. Ethics is everyone’s responsibility
• The relationship of patient to
his physician is by its very
nature one of the most
intimate
• Foundation: doctor is learned,
skilled & experienced in
afflictions of body about which
patient ordinarily knows little
(but are very imp for him)

13. Ethics is everyone’s
responsibility
• Patient must place great
reliance, faith & confidence in
the professional
word/advice/acts of doctor
• Doctor must act with utmost
good faith & to speak fairly &
truthfully to the peril of being
held liable for damages for deceit
or fraud

14. Fundamental Right
• No person shall be deprived of
his life (life with human
dignity)
• Emergency care is right of
every citizen
• When a person who is innocent
or criminal has met with an
accident, it is the obligation of
health providers to protect his
life

15. Legal Necessity
• Every doctor under law
bound by a contract to serve
its patient and cannot refuse
treatment. Every doctor has
to fulfill certain legal
requirements in service by
compulsion or voluntarily as
defined under law.

16. Building Confidence
•A good working
knowledge of the law in
this regard, coupled with a
thorough understanding of
the correct method of
dealing with legal aspects
helps one to build
confidence over riding the
fear of LAW

17. Medical Laws
• The Legal aspects of medical
practice broadly covers two
areas of medical laws:
Medical Jurisprudence : It
deals with legal aspects of
medical practice.
• Forensic Medicine : It deals
with medical aspects of law.

18. Sources of Law
• PRIMARY SOURCES: Laws passed by the
Parliament or the State Legislative
• Ordinances passed by the President and the
Governor
• Subordinate legislation: Rules and regulations
made by the executive through the power
delegated to them by the Acts.
• SECONDARY SOURCES: Judgments of the
Supreme Court, High Court and Tribunals (The
ratio decedendi is a binding precedent)
• Judicial legislation
• Judgment of Foreign Courts
• International Treaty

19. MEDICALETHICSANDCONDUCT
• Apart from his routine and usual “clinical”
cases, a doctor will come across certain
‘Medicolegal’ issues at one time or the
other during the practice of his profession.
• Duties and obligations of doctors are
enlisted in the laws of the land and
different Codes of Medical Ethics and
Declaration:
 Hippocratic Oath
 Declaration of Geneva
 Declaration of Helsinki on medical
research
 International Code of Medical Ethics

20. Declaration of Geneva
• The Declaration of Geneva of the
WMA binds the physician with
the words, "The health of my
patient will be my first
consideration,“ and the
International Code of Medical
Ethics declares that, "A physician
shall act in the patient's best
interest when providing medical
care

21. Legal responsibility of hospital
• Hospital is a public institution
• Deals with life and death
• Hence carries specified responsibilities &
liabilities within and outside the hospital
• Failure to comply invites legal action
• Legal responsibilities are bound to
different category of people and
institution by contracts
• Breach of any contract held the hospital
legally responsible

22. Emergency Doctrine
• In Emergencies, CONSENT
can be implied in the law if
immediate treatment is
necessary to avoid life- or
limb-threatening condition
• Clinical management should
precede the legal duties in
trauma cases brought for
treatment

23. Medical Negligence
• A doctor must posses a
reasonable degree of
proficiency & apply the
proficiency with a reasonable
degree of diligence
• Failure of the doctor to provide
medical services (with requisite
skill & care) gives rise to action
in medical negligence under
criminal, civil or consumer court

24. Medical Negligence
• A doctor is negligent if he
doesn't offer his services in
an emergency situation
• A doctor breaches his duty of
care when he fails to reach
the standard of proficiency
expected of him

25. Legal concept of Negligence
• Human Behaviour towards
others: failure to act reasonably
& prudently
• Failure or breach of duty owed to
the patient doctor has the
obligation to perform that duty in
a manner that will bring it to a
successful conclusion)
• Damage to the individual for
breach of duty (there must be some
damage to the patient resulting from breach
of duty owed)

26. Medical malpractice
• The plaintiff must prove that the
treatment given was below the
degree and skill expected of a
competent doctor and that the
negligence proximately caused
the injury or death……….. The
bare possibility of causation will
not suffice

27. TORT
• Civil wrong (negligence) committed
by one individual against another is
known as TORT, where, a person fails
to take proper care, so that damage
results
• Civil Law deals with legal actions
which seek the redress of wrongs
which are not criminal in nature
• Criminal Law involves a legal action
filed by a state government against
defendants and deals with definitions
of crimes and their punishment

28. Negligence
• Harmful conduct that deviates
from accepted standards of duty
& care
• A doctor who injures a patient by
conduct that fails to meet the
legal standard of due care may
be liable for negligence in an
action for malpractice

29. Specific elements of Negligence
In order for a complaining party to
sustain an action for negligence against
a defending party, 4 elements must be
proved in the court of law:
• Existence of doctor-patient relationship
giving rise to a duty of due care
• Breach of that duty
• Proximate cause (injury): Fall from a
Stretcher in ED sustains bruises/MI after 4 months;
is unlikely to rove that the fall caused MI
• Damages

30. Res Ipsa Loquitur
• In most malpractice cases, the
plaintiff is required to prove
negligence through the testimony of
an expert medical witness
• An exception: doctrine of res ipsa
loquitur (the thing speaks for itself):
when medical mishap could not be
due to someone’s negligence
(presence of a sponge or clamp in the
body cavity of a patient who has had
surgery is a self-evident indication of
negligent conduct by some member of
the operating team)

31. Error of Clinical Judgment
• Some mishaps are unavoidable,
being within the wide range of
variability and uncertainty that is
inherent in biological processes
• Common causes for negligent
actions include failure to attend,
amputation of wrong limb or
digit, missed fractures,, tight
plaster casts, poor results from
spinal procedures, damage to
newborn from anoxia or forceps

32. Error of clinical judgment - II
• Removal of healthy kidney
instead of pathological
• Operation on healthy eye
• Leaving gauze or instrument in
the body cavity during surgery
• Anesthetic errors
• Not performing sensitivity tests
for certain drugs before
administering
• Failed tubal sterilization

33. Malpractice
• Professional negligence
• Lack of reasonable care &
skill
• Willful negligence in the
treatment of a patient
whereby the health or life of
a patient is endangered

34. Criminal Negligence
• Negligence is so great as to go
beyond matter of mere
compensation
• Not only the doctor has made
wrong diagnosis and treatment,
but he/she has shown gross
neglect for life and safety of the
patient
• Doctor may be prosecuted for
having caused injury or death of a
patient by a rash & negligent act
amounting to culpable homicide

35. CONSENT
• One of the most basic human rights
is freedom from physical interference
• A person of sufficient maturity and
mental capacity can choose whether
to submit to the ministrations of a
doctor
• With few exceptions, consent to
examination is an absolute
prerequisite before a doctor
approaches the patient
• Failure to obtain consent may lead to
recovery of damages in a civil action

36. Battery
•Battery: an unpermitted
contact with the patient
•A clinician who fails to
obtain consent for
treatment or who provides
treatment beyond or
contrary to what the patient
has consented to

37. Types of Consent
• Implied Consent: is provided by the
behaviour of the patient; e.g. patient
presents at Outpatient Clinic
• Express Consent: Any thing other
than implied consent. It may be oral
or written
• Informed Consent: consent must be
obtained after a reasonable
explanation of the proposed
procedure to patient, so that he is
enable to make informed decision
whether or not to submit

38. The Extension Doctrine
• Provides an exception to the general
rule that a patient’s consent is limited
to those procedures contemplated
when consent is given
• If in the course of authorized medical
intervention a doctor discovers a life-
threatening condition that requires
immediate treatment and the patient
is unable to consent (e.g. under
anesthesia), the doctor may extend
the operation or procedure without
the patient’s express consent

39. Therapeutic privilege
• A situation where full disclosure to the
patient might be harmful and therefore
contraindicated, a doctor may have a
therapeutic privilege to withhold
information
• This privilege avails only when the
patient’s distress and apprehension are
so great that full disclosure of all risks
might cause emotional harm or induce
the patient to refuse treatment, fail to
cooperate with treatment, or make an
irrational choice of treatment
alternatives
• Used in rare circumstances only

40. Medical reports & certificates
• Reports on the medical conditions
of a person (victim or
accused)folowing injury
• Death certificate
• Reports for Life-insurance
• Certificate of illness
• Certificate of fitness
• All these documents must be
prepared with meticulous accuracy

41. Sexual Assault (Rape)
• Rape is a legal conclusion and not
a medical diagnosis
• The medical diagnosis of a rape
victim should be limited to the
actual clinical findings at the time
of examination
• If female Gynecologist fail to reach
the fact definitely, or if
circumstances so demand, take the
judge permission to have the
victim examined by male forensic
doctor

42. Medical Exam. of a female
The medical examination by a
Gynecologist or Forensic
Doctor of a woman subjected
to sexual assault shall be
done in presence of:
• guardian
• female general practitioner
• nurse

43. Report
Incidents requiring a report
to the proper official relevant
agencies while maintaining
as much patient
confidentiality as possible,
include:
• Drug & chemical poisoning
• Road traffic accident
• Gun-shot wounds
• Physical assault

44. Gunshot & Stab Wounds
•Reports of
these acts of
violence are
usually made
to police

45. Dead-on-Arrival
• If the case of death is natural, death
certificate & burying license must be
submitted to relatives
• Un-natural death: be reported to police
for possible investigation & for
assessment of need for a referral to
forensic medicine sp.
• Initiate resuscitation unless it is clear
that patient has been dead for some
time
• Mention that deceased was brought
dead
• Body to be examined by a committee
• In case there is no clear cause of death,
take 50 ml blood in plain tube & send to
Toxicology Centre

46. Cause of Death
• In case the results (from
toxicology lab) are negative, the
cause of death can be mentioned
as “Death possible due to hidden
disease leading to
cardiopulmonary arrest”
• All dead bodies should be kept
for 2 hours before transferring to
mortuary
• Patient’s belongings should be
handed over to relatives, if the
cause of death is natural.

47. Medico-legal cases
• A case or injury or ailment
where an attending doctor after
taking history & clinical
examination of the patient,
thinks that some investigation
by law-enforcing agencies are
essential so as to fix
responsibility regarding the case
in accordance with the law of
the land

48. Medico-legal cases
• Motor vehicle accidents (RTAs)
• Factory/industry accidents
• Suspected homicide, suicide
• Poisoning
• Burn injuries
• Injury where foul play is suspected
• Sexual offenses
• Unconscious cases where cause is not
known
• Cases brought dead with improper
history
• Cases referred by Court

49. MLC Injury Report
• Must be prepared on the appropriate form
• Should be written in a neat and legible
handwriting by the examining doctor
• Report should be completed as early as
possible after examining the person
• Time of examination along with date
• Where nature of injury cannot be
ascertained, patient must be kept under
observation and admitted in ward
• General physical examination should
always be undertaken & findings recorded
• Opinion will depend on X-ray & other
reports

50. Preservation of trace evidence
• All clothing worn by an
injured and removed in the
hospital shall be preserved,
packed after drying
• Gastric lavage, bullet pellets
etc. taken out of the body of
a patient be preserved in
sealed containers & labeled
properly, preserved under
safe custody

51. Doctor’s Defence
• When something untoward
happens following a diagnostic or
therapeutic procedure, the doctor
must take following step/s:
– complete the patient’s record & recheck
the written notes
– be frank enough and inform clearly of the
mishap and show genuine concern about
the unfortunate mishap
– contact professional bodies to seek advice
– professional indemnity insurance cover

52. Hospital: A Glimpse

53. Health Law
• field of legal practice,
scholarship and law reform
relating to the delivery of health
care
• deals with health care delivery at
macro and micro level
• rapidly expanding and dynamic
field - scientific, social,
economic, legal, philosophical
and political influences

54. Why Study Health Law?
• all aspects of the practice of
medicine, and healthcare more
broadly, are affected by the law
• important for physicians to have
an awareness of how the law
affects them and their patients
• Medical Council of India expects
competency in this area

55. Influences on Development of Health Law
• health care reform movement (re
organization and financing of
health care system)
• increasing litigation and new
types of litigation
– e.g. class action suits re medical
devices
– wrongful life lawsuits

56. Influences on the Development of
Health Law
• advances in science and technology
– e.g. genetic research
– reproductive technologies
• advances in information technology
– computerized patient information
– vast amount of health info on the
internet
• evolution of field of bioethics,
increasing influence of new
perspectives

57. Law and Ethics
• law influenced by ethics and to some
extent the converse is true
• obviously important to comply with the
law, but what the law says may not be
the ultimate answer to a moral question
• many ethical principles re medical
practice now codified - tends to blur the
distinction (rules-based vs. virtue
ethics)
• some similarities in reasoning -
clarifying facts, principles and their
application

58. Overview of the Indian
Legal System
•where does the law come
from?
•areas of law
•Indian constitutional
framework
•the court system

59. Sources of Law
• Legislation
–statutes
–regulations
–federal and provincial
• Judicial Decisions
–sometimes referred to as the
“common law”
–precedents

60. Nature of the Law
•degree of uncertainty
•role of judicial
interpretation
•constantly evolving

61. Divisions of Law
• Public Law
– disputes between individual and
state
– e.g. criminal law, administrative
law, constitutional law
• Private Law
– sometimes referred to as “civil law”
– disputes between individuals
– e.g. torts, contracts, property law

62. Health Law Topics
• Country’s health care system
– structure, funding, supply of and
access to health services
• regulation of health professionals
e.g. MD’s
• medical negligence
• consent
• confidentiality and disclosure of
health information

63. Health Law Topics
• medical care of minors
• medical care of patients with
mental disabilities
• abortion
• regulation of reproductive
technologies
• genetics and the law
• end of life decision making
• medical research

64. Regulation of the Medical Profession
• state responsibility
• “self-regulating” professions
• body created by statute in each
province
– e.g. Medical Board
– standards for licensure
– deals with allegations of
incompetence, incapacity or
misconduct
– can generate its own policies,
guidelines

65. Civil Liability
• a.k.a. negligence,
“malpractice”, “getting sued”
• law in this area mostly
“judge-made”
• informed consent
• standard of care

66. Complex Emerging Issues
– e.g. reproductive technologies
– electronic health care records -
privacy issues
– cost constraints - impact on insured
services and on individual care
• complex issues affected by
several sources and divisions of
law (courts, legislatures, federal,
provincial, criminal, civil, Charter
of Rights) as well as ethics,
public policy

67. Laws Applicable to EMS
• Legal vs. Ethical vs. Moral
Responsibilities
• Review of the Legal System
• Specific Laws Applicable to EMS
• Accountability & Malpractice
• Specific Paramedic-Patient
Issues
• Operational Issues
• Documentation

68. Legal vs. Ethical vs. Moral
Responsibilities
• What are the
differences?
–Legal
Responsibilities
–Ethical Standards
–Morality

69. The Legal System
• Sources of Law
– Constitutional
– Common
– Legislative
– Administrative
• Legislative and Administrative
are often the focus of EMS
Providers

70. The Legal System
•Federal vs. State Court
•Categories of Law
–Criminal Law
–Civil Law
•Tort Law
What are examples of how each of these may affect the paramedic?

71. The Legal System
• Terminology
–Plaintiff
–Defendant
–Discovery phase
•Deposition
•Interrogation
•Documentation
–Appeal

72. Laws Affecting EMS
• Motor Vehicle Laws
• Infectious Disease Exposure
• Assault against Public Safety
Officer
• Obstruction of Duty
• Good Samaritan Law: offering
legal protection to an individual who
voluntarily provides care during an
emergency situation

73. Does India Need A Good Samaritan Law?
• According to WHO accidents kill
more than 200 people on roads
every day in India. You must
have awed at the number and
must have even cursed the
people who were the cause for
such a loss. However do you
know more than those rash
drivers you are also one of the
reason for such a loss.

74. Laws Affecting EMS
• Mandatory Reporting
– Domestic violence
– Child & Elder abuse
– Criminal Acts
– GSW, Stabbing & Assault
– Animal Bites
– Communicable Diseases
– Out of hospital deaths
– Possession of Controlled
Substances

75. Accountability & Malpractice Issues
• Standard of Care
• Negligence
• Civil Litigation Specifics
• Borrowed Servant Doctrine
• Patient Civil Rights
• Liability when off-duty

76. Borrowed Servant Doctrine
• The common law principle
that the employer of a
borrowed employee, rather
than the employee’s regular
employer, is liable for the
employee’s actions that occur
while the employee is under
the control of the temporary
employer.

77. Accountability & Malpractice
• Standard of Care
– The expected care, skill, & judgment under
similar circumstances by a similarly trained,
reasonable paramedic
• Negligence
– Deviation from accepted or expected
standards of care expected to protect from
unreasonable risk of harm
What are the required components for proof of a
negligence claim in EMS?

78. Accountability & Malpractice
• Civil Cases
– Proof of guilt required by a
“preponderance of evidence”
– “res ipsa loquitur”
• Burden of proof shifts to the defendant
• Simple vs. Gross Negligence

79. Defenses
• Good Samaritan Law
• Government Immunity
• Statue of Limitations
• Contributory Negligence

80. Accountability & Malpractice
• How do these affect the Paramedic’s
Practice?
– Borrowed Servant Doctrine
– Patient Civil Rights
– Liability when Off-Duty

81. Specific Paramedic-Patient
Issues
• Issues Surrounding
Consent
• Refusals
• Restraint
• Abandonment
• Transfer of Patient
Care
• Advance Directives
& End of Life
Decisions
• Out of Hospital
Death
• Confidentiality &
Privacy

82. Specific Paramedic-Patient
Issues
• Issues Surrounding Consent
– Patient has legal & mental capacity
– Patient understands consequences
– Types of Consent
• Informed
• Expressed
• Implied
• Involuntary

83. Specific Paramedic-Patient
Issues
• Issues Surrounding Consent
– Specific Consent Issues
• Minors
• Emancipated Minor
• Prisoners

84. Specific Paramedic-Patient
Issues
• Refusals
– Consent for Transport vs. Treatment
– Withdrawing Consent
– Refusal of Service
• Has legal & mental capacity
• Is informed of risks & benefits
• Offer alternatives
• All of the above are well documented &
witnessed

85. Specific Paramedic-Patient
Issues
• Refusals
– Incompetent Persons
• Unable to understand the nature &
consequences of his/her injury/illness
• Unable to make rational decisions regarding
medical care due to physical or mental
conditions
• Do not assume incompetence unless
obvious

86. Specific Paramedic-Patient
Issues
• Restraint
– Definitions
• Assault
• Battery
• False Imprisonment

87. Specific Paramedic-Patient
Issues
• Restraint
– In Custody of Law Enforcement or
Corrections
– Patient is not competent to refuse &
requires care
– Patient is a danger to self or others
(involve law enforcement)
– Does not provide authorization to harm!

88. Specific Paramedic-Patient
Issues
• Restraint
– Involve Law Enforcement Early
– Have a plan of action
– Ensure safety of all
– Reasonable force
– Physical restraints
– Chemical restraints
– Document well

89. Specific Paramedic-Patient
Issues
• Patient Abandonment
– Unilateral termination of the patient-
provider relationship
• Still needed and desired
– Exceptions
• MCI
• Risks to well-being
Can a paramedic turn over care of a patient to an EMT?

90. Specific Paramedic-Patient
Issues
• Transfer of Patient Care
– Transfer of Care to other Providers
– Transfer of Care at the ED

91. Specific Paramedic-Patient
Issues
• Advanced Directives & End of Life
Decisions
– Definitions
• Advanced Directive
• Out of Hospital DNR
• DNR vs. DNAR
• Living Will
• Durable Power of Attorney for Health Care
• Patient Self-Determination Act

92. Specific Paramedic-Patient
Issues
• Advanced Directives & End of Life
Decisions
– Living Will
– Durable Power of Attorney for Health Care
– Out of Hospital DNR
• Terminal Condition no longer required
• Identification Devices
• EMS requirements
• Revocation
Can a Paramedic honor an Advanced Directive
(other than a DNR)?

93. Specific Paramedic-Patient
Issues
• Advanced Directives & End of Life
Decisions
– Patient does not surrender rights to
receive medical care
– Comfort measures appropriate
– Provide Family support and guidance
– When in doubt, resuscitate & contact
medical control
– Termination of efforts allowed

94. Specific Paramedic-Patient
Issues
• Out of Hospital Death
– Initiation of care?
– Many counties and cities require:
• law enforcement response and/or
• Justice of the peace pronouncement
– Some jurisdictions use a medical
examiner or coroner system
– Required medical control authorization
– Survivors may now be the patients

95. Specific Paramedic-Patient
Issues
• Patient Confidentiality & Privacy
– “Medical information about a patient will
not be shared with a third party without
consent, statute, or court order”
– Not all information is protected
– In some states, QA/QI information is
not discoverable

96. Specific Paramedic-Patient
Issues
• Patient Confidentiality & Privacy
– Colleague & Station Talk
• Must not identify the patient
• Maintains confidentiality of specific medical
info
– Scene or Patient Photographs
– EMS Radio Dispatch & Discussions
– “Need to Know” Basis

97. Specific Paramedic-Patient
Issues
• Patient Confidentiality & Privacy
– You have treated & transported a 50-year-
old local salesman who is originally
diagnosed in the ED with PCP. At the
station, you discuss this case including the
name of the patient’s business. Since PCP
is associated with HIV/AIDS, your coworker
suspects this man is infected. Your
coworker discusses this case with a friend
(the patient’s employer) who then discusses
this matter with your patient (his
employee). (cont’d)

98. Specific Paramedic-Patient
Issues
Group Discussion: Patient
Confidentiality & Privacy
1. What are the possible consequences
for you?
2. What if the patient does not have
HIV/AIDS?

99. Specific Paramedic-Patient
Issues
• Patient Confidentiality & Privacy
– Defamation
• “Communication of false information
knowing the information to be false or with
reckless disregard of whether it is true or
false”
• Slander
• Libel
– Protected Classes/Diseases

100. Operational Issues
• Equipment failure
• Interaction with
Law Enforcement
– Crime Scenes
– Preservation of
Evidence
• Vehicle Operation
• Medical Control
• Instructor Liability
• Hospital Selection
• Dispatch
• Interfacility
Transfers
• OSHA
• Risk Management

101. Operational Issues
• Equipment Failure
– Product Liability
• Design flaw in ventilator
– Failure on part of owner/operator
• No backup battery for defibrillator

102. Operational Issues
• Interaction with Law Enforcement
– Crime Scenes
• Request law enforcement
• Await law enforcement arrival if possible
• Minimize areas of travel and contact with
scene
• Document any alterations to the scene
created by EMS personnel
• Minimize personnel within scene if possible
• Document pertinent observations

103. Operational Issues
• Interaction with Law Enforcement
– Evidence Preservation
• Avoid cutting through penetrations in the
clothing
• Save everything – clothing of assault victim,
items found on person, etc
• Prevent sexual assault victim from washing
• Follow sound chain of evidence procedures

104. Operational Issues
• Vehicle Operation
– It is 3:00 am. While responding to a
MVC, a driver fails to yield the right of
way at an intersection. The driver’s
traffic signal is green. You attempt to
stop but are unable to do so. Witnesses
state your emergency lights were on but
do not recall hearing your siren. The
driver is injured.
(cont’d)

105. Operational Issues
• Vehicle Operation
– What issues might the driver’s attorney
consider?
• Were all of your emergency lights really
operational? Are daily inspections
performed?
• Why was the siren not working?
• Were poorly maintained brakes responsible
for your inability to stop? What type of PM
is performed on your ambulance?
• Did you exercise due regard for the safety
of others?

106. Operational Issues
• Medical Control Issues
– Failure to follow med contr direction
– Following obviously harmful direction
– Implementing therapies without prior
authorization
– Following direction of an unauthorized person
– Med Contr directs EMS to an inappropriate
hospital
– The paramedic exceeds the scope of his
training or medical authorization

107. Operational Issues
• Instructor Liability
– Student discrimination
– Sexual harassment
– Student injury during laboratory
– Patient claim re. Failure to properly train
graduate or supervise student
– Instructors – Follow curriculum,
document student attendance &
competency

108. Operational Issues
• Hospital Selection
– Paramedic & Medical Control decision
– Closest & Appropriate Facility
– Written policies or guidelines
What is the closest & most appropriate facility? What does this mean?

109. Operational Issues
• Dispatch Issues
– Untimely dispatch
– Failure to provide responding units with
adequate directions (incorrect address)
– Dispatch of inadequate level of care
– Failure to provide pre-arrival
instructions
– Inadequate recordkeeping

110. Operational Issues
• Interfacility Transfer Issues
– Do you have the necessary equipment &
training?
– Should any specialized providers accompany
you?
– Do you have a patient report including history?
– Is the patient “stable”? What are the potential
complications?
– Are there any specific physician orders?
– Does the patient have a DNR order?
– Has the patient been accepted (MOT)? Who
are the transferring & accepting physicians?

111. Operational Issues
• OSHA & Risk Management
– OSHA generally not applicable to government
employees
• New Texas Sharp Injury Prevention Rules
– In many States, State OSHA Rules are
applicable to nearly all
– “Each employee shall comply with occupational
safety and health standards and all rules,
regulations, and orders issued persuant to this
Act which are applicable to his own actions and
conduct”

112. Documentation
• Patient Confidentiality
• Securing/Sharing/Requests for
Information
• Protected Classes
• Quality & Effectiveness

113. Documentation
• Patient Confidentiality
– Written report only intended for those
with a need to know
– Personal identifiers may be removed for
QA/QI uses
– Patient radio reports should not contain
personal identifiers

114. Documentation
• Securing/Sharing/Requests for
Information
– Where are completed patient reports
stored?
– Who received the report at the ED?
– Requests for copies should be routed
through an accepted policy or an
attorney
– Does the requestor have a need to
know?

115. Documentation
• Protected Classes
– In some states, patient information
related to sexually transmitted diseases
or other specific diseases has become
protected as confidential
– Washington state
• Can not refer to HIV/AIDS or STD status in
report without consent
• Then, only with a clear need to know

116. Documentation
• Quality & Effectiveness
– Complete soon after the patient contact
– Be thorough and accurate
– Be honest, objective and factual
– Caution with abbreviations
– Maintain confidentiality
– Do not alter

117. Documentation
• Quality & Effectiveness
– Does your report relay to future
healthcare providers the information
you obtained regarding this patient?
– Is the information clear and concise?
– Will the report help you recall this
incident if necessary 3 years from now?
– Are you willing to sit in court with only
this document?

118. Summary
• There are many legal
issues surrounding the
EMS environment
• The paramedic should
attempt to keep up-to-
date with local legal
requirements
• Ignorance is not
acceptable!

119. Medical, Legal,
and Ethical Issues

120. National EMS Education
Standard Competencies (1 of
3)
Preparatory
Uses simple knowledge of the
emergency medical services (EMS)
system, safety/ well-being of the
emergency medical responder (EMR),
and medical/legal issues at the scene
of an emergency while awaiting a
higher level of care.

121. National EMS Education
Standard Competencies (2 of
3)
Medical/Legal and Ethics
• Consent/refusal of care
• Confidentiality
• Advance directives
• Tort and criminal actions
• Evidence preservation
• Statutory responsibilities

122. National EMS Education
Standard Competencies
Medical/Legal and Ethics (cont’d)
• Mandatory reporting
• Ethical principles/moral obligations
• End-of-life issues

123. Introduction
• Laws differ from one location to
another, so EMRs should learn the
specific laws that apply in their state
or jurisdiction.
• Do not lose sight of these concepts:
– Above all else, do no harm.
– Provide all your care in good faith.
– Provide proper consistent care, be
compassionate, and maintain your
composure.

124. Duty to Act (1 of 2)
• If you are employed by an agency
as an EMR and you are dispatched
to the scene of an accident or
illness, you have a duty
to act.
– You must proceed promptly to the
scene and render emergency medical
care within the limits of your training
and available equipment.

125. Duty to Act (2 of 2)
• Failure to
respond or
render care
leaves you and
your agency
vulnerable to
legal action.
Credit: © Corbis

126. Standard of Care
• The standard of care is the manner
in which you must act or behave.
• You must meet two criteria:
– You must treat the patient to the best
of your ability.
– You must provide care that a
reasonable, prudent person with similar
training would provide under similar
circumstances.

127. Scope of Care
• Scope of care is defined by:
– The US Department of Transportation,
Emergency Medical Responder
Educational Standards
– Medical protocols or standing orders
– Online medical direction

128. Ethical Responsibilities
and Competence (1 of 2)
• Treating a patient ethically means
doing so in a manner that conforms
to accepted professional standards
of conduct.
– Stay up-to-date on skills and
knowledge.
– Review your performance and assess
your techniques.
– Evaluate your response times.
– Take continuing education classes.

129. Ethical Responsibilities
and Competence (2 of 2)
• Ethical behavior requires honesty.
– Always provide complete and correct
reports to other EMS providers.
– Never change a report except to
correct an error.

130. Consent for Treatment (1 of 4)
• Consent simply means giving
approval or permission.
• Expressed consent
– The patient actually lets you know—
verbally or nonverbally—that he or she
is willing to accept treatment.
– The patient must be of legal age and
able to make a rational decision.

131. Consent for Treatment (2 of 4)
• Implied consent
– The patient does not specifically refuse
emergency care.
– Do not hesitate to treat an unconscious
patient.
• Consent for minors
– Under the law, minors are not
considered capable of speaking for
themselves.

132. Consent for Treatment (3 of 4)
• Consent for
minors (cont’d)
– Emergency
treatment must wait
until a patient or
legal guardian
consents to the
treatment.
– If permission cannot
be quickly obtained,
do not hesitate to
give appropriate
medical care.

133. Consent for Treatment (4 of 4)
• Consent of mentally ill patients
– If the person appears to be a threat to
self or others, place this person under
medical care.
– Know your state’s legal mechanisms for
handling these patients.
– Do not hesitate to involve law
enforcement agencies.

134. Patient Refusal of Care (1 of 2)
• Any person who is mentally in
control has a legal right to refuse
treatment.
• Help the person understand the
consequences of refusing care by
explaining:
– The treatment
– The reason that the treatment is
needed
– The potential risks if treatment is not

135. Patient Refusal of Care (2 of 2)
• Patient refusals should be
documented on your patient care
record according to your agency
protocols.

136. Advance Directives (1 of 3)
• An advance directive is a document
that specifies what a person would
like to be done if he or she becomes
unable to make his or her own
medical decisions.
• A living will
– Written document drawn up by a
patient, a physician, and a lawyer
– States the types of medical care the
person wants or wants withheld

137. Advance Directives (2 of 3)
• A durable power of attorney for
health care
– Allows a patient to designate another
person to make decisions about
medical care
• A do not resuscitate (DNR) order
– Written request giving permission to
medical personnel not to attempt
resuscitation in the event of cardiac
arrest

138. Advance Directives (3 of 3)
• If you are unable to determine if an
advance directive is legally valid,
begin appropriate medical care.
– Some states have systems in place,
such as bracelets, to identify patients
with advance directives.

139. Abandonment
• Abandonment occurs when a trained
person begins emergency care and
then leaves the patient before
another trained person takes over.
• Once you have started treatment,
you must continue it until a person
who has at least as much training
arrives and takes over.

140. Persons Dead at the Scene
(1 of 2)
• If there is any indication that a
person is alive, you should begin
providing care.
• You cannot assume a person is dead
unless one of these conditions
exists:
– Decapitation
– Rigor mortis
– Tissue decomposition

141. Persons Dead at the Scene
(2 of 2)
• If any of the signs
of death are
present, consider
the patient to be
dead.
• It is important that
you know the
protocol your
department uses in
dealing with
patients who are
dead on the scene.
Credit: © Damian Dovarganese/AP Photos

142. Negligence
• Negligence occurs when a patient
sustains further injury or harm
because the care administered did
not meet standards.
• These conditions must be present:
– Duty to act
– Breach of duty
– Resulting injuries
– Proximate cause

143. Confidentiality (1 of 2)
• Most patient information is
confidential.
– Patient circumstances
– Patient history
– Assessment findings
– Patient care given
• Information should be shared only
with other medical personnel.

144. Confidentiality (2 of 2)
• In certain circumstances, you may
release confidential information to
designated individuals.
• Health Insurance Portability and
Accountability Act of 1996 (HIPAA)
– Strengthens laws for the protection of
the privacy of health care information
and safeguards patient confidentiality

145. Good Samaritan Laws
• Protect citizens from liability for
errors or omissions in giving good-
faith emergency care
• Vary considerably from state to
state
• May no longer be needed
– Provide little or no legal protection for a
rescuer or EMS provider

146. Regulations
• Become familiar with the federal,
state, local, and agency regulations
that affect your job.
• Certification or registration may be
required to work as an EMR.
• You are responsible for keeping
certifications or registrations
current.

147. Reportable Events (1 of 2)
• Reportable crimes include:
– Knife wounds
– Gunshot wounds
– Motor vehicle collisions
– Suspected child or elder abuse
– Domestic violence
– Dog bites
– Rape

148. Reportable Events (2 of 2)
• Learn which crimes are reportable in
your area.
• Failure to notify proper authorities of
reportable events may result in
sanctions against you or your
agency.

149. Crime Scene Operations (1 of
3)
• Many emergency medical situations
are also crime scenes.
• Keep these considerations in mind:
– Protect yourself.
– If you determine that a crime scene is
unsafe, wait until law enforcement
personnel give you the signal that the
scene is safe for entry.
– Your priority is patient care.

150. Crime Scene Operations (2 of
3)
• Considerations: (cont’d)
– When you are assessing the scene,
document anything that seems
unusual.
– Move the patient only if necessary.
– Touch only what you need to touch to
gain access to the patient.
– Preserve the crime scene for
investigation.
– Do not cut through knife or bullet holes

151. Crime Scene Operations (3 of
3)
• Considerations:
(cont’d)
– Be careful where you
place equipment.
– Keep nonessential
people away.
– Work with the
appropriate law
enforcement
authorities on the
scene.
– Write a short report
about the incident.
Credit: © Bob Child/AP Photos

152. Documentation (1 of 3)
• Your documentation is the initial
account describing the patient’s
condition and the care administered.
– Serves as a legal record of your
treatment
– Provides a basis for evaluating the
quality of care provided
– Should be clear, concise, accurate, and
readable

153. Documentation (2 of 3)
• Documentation should include:
– Condition of the patient when found
– Patient’s description of the
injury/illness
– Patient’s initial and repeat vital signs
– Treatment you gave the patient
– Agency and personnel who took over
treatment of the patient
– Any reportable conditions present

154. Documentation (3 of 3)
• Documentation should include:
(cont’d)
– Any infectious disease exposure
– Anything unusual regarding the case

155. Summary (1 of 3)
• As an EMR, you have a duty to act
when you are dispatched on a medical
call as a part of your official duties.
• You should understand the differences
between expressed consent, implied
consent, consent for minors, consent
of mentally ill persons, and the right to
refuse care.

156. Summary (2 of 3)
• Advance directives give a patient
the right to have care withheld.
• You should understand the concepts
of abandonment, negligence, and
confidentiality, as well as the
purpose of Good Samaritan laws.

157. Summary (3 of 3)
• Certain events that deal with
contagious diseases, abuse, or
illegal acts must be reported to the
proper authorities.
• Crime scene operations are a
complex environment.

158. Review
1.Emergency medical responders
have the legal duty to act:
A.only when they are being
compensated by a certified agency.
B.if they witness an emergency scene
while not on duty.
C.even when outside of their response
jurisdiction.
D.if they are employed by an agency as
EMRs.

159. Review
Answer:
D. if they are employed by an
agency
as EMRs.

160. Review
2.Patients are legally able to make a
decision regarding their care if they:
A. are of legal age according to state law.
B. have injuries that are not life
threatening.
C. willingly accept transport to the
hospital.
D. have bystanders who can verify their
competency.

161. Review
Answer:
A. are of legal age according to
state law.

162. Review
3.EMRs have the ethical responsibility
to:
A. provide care only when a paramedic is
present.
B. discuss details of each case with their
coworkers and families.
C. transport all patients to the closest
hospital.
D. conform to accepted professional
standards of conduct.

163. Review
Answer:
D. conform to accepted
professional standards of
conduct.