Medical/Legal Aspects of
Prehospital Care
Department of EMS Professions
Temple College
Topics to Discuss
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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
Legal vs. Ethical vs. Moral
Responsibilities
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What are the
differences?
Legal Responsibilities
 Ethical Standards
 Morality
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The Legal System
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Sources of Law
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Constitutional
Common
Legislative
Administrative
Legislative and Administrative are often
the focus of EMS Providers
The Legal System
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Federal vs. State Court
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Categories of Law
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Criminal Law
Civil Law
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Tort Law
What are examples of how each of these may affect the
paramedic?
The Legal System
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Terminology
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Plaintiff
Defendant
Discovery phase
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Deposition
Interrogation
Documentation
Appeal
Laws Affecting EMS
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Scope of Practice
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Texas
Medical Direction
Intervener physician
Ability to Practice
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Certification or Licensure
Authorization to Practice
Laws Affecting EMS
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Motor Vehicle Laws
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Infectious Disease Exposure
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Assault against Public Safety Officer
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Obstruction of Duty
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Good Samaritan Law
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Ryan White CARE Act
Laws Affecting EMS
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Mandatory Reporting
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Domestic violence
Child & Elder abuse
Criminal Acts
GSW, Stabbing & Assault
Animal Bites
Communicable Diseases
Out of hospital deaths
Possession of Controlled Substances
Accountability & Malpractice
Issues
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Standard of Care
Negligence
Civil Litigation Specifics
Borrowed Servant Doctrine
Patient Civil Rights
Liability when off-duty
Accountability & Malpractice
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Standard of Care
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The expected care, skill, & judgment under similar
circumstances by a similarly trained, reasonable
paramedic
Negligence
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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?
Accountability & Malpractice
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Civil Cases
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Proof of guilt required by a “preponderance
of evidence”
“res ipsa loquitur”
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Burden of proof shifts to the defendant
Simple vs. Gross Negligence
Defenses
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Good Samaritan Law
Government Immunity
Statue of Limitations
Contributory Negligence
Accountability & Malpractice
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How do these affect the Paramedic’s
Practice?
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Borrowed Servant Doctrine
Patient Civil Rights
Liability when Off-Duty
Specific Paramedic-Patient
Issues
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Issues Surrounding
Consent
Refusals
Restraint
Abandonment
Transfer of Patient
Care
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Advance Directives
& End of Life
Decisions
Out of Hospital
Death
Confidentiality &
Privacy
Specific Paramedic-Patient
Issues
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Issues Surrounding Consent
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Patient has legal & mental capacity
Patient understands consequences
Types of Consent
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Informed
Expressed
Implied
Involuntary
Specific Paramedic-Patient
Issues
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Issues Surrounding Consent
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Specific Consent Issues
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Minors
Emancipated Minor
Prisoners
Specific Paramedic-Patient
Issues
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Refusals
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Consent for Transport vs. Treatment
Withdrawing Consent
Refusal of Service
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Has legal & mental capacity
Is informed of risks & benefits
Offer alternatives
All of the above are well documented &
witnessed
Specific Paramedic-Patient
Issues
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Refusals
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Incompetent Persons
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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
Specific Paramedic-Patient
Issues
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Restraint
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Definitions
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Assault
Battery
False Imprisonment
Specific Paramedic-Patient
Issues
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Restraint
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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!
Specific Paramedic-Patient
Issues
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Restraint
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Involve Law Enforcement Early
Have a plan of action
Ensure safety of all
Reasonable force
Physical restraints
Chemical restraints
Document well
Specific Paramedic-Patient
Issues
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Patient Abandonment
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Unilateral termination of the patientprovider relationship
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Still needed and desired
Exceptions
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MCI
Risks to well-being
Can a paramedic turn over care of a patient to an EMT?
Specific Paramedic-Patient
Issues
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Transfer of Patient Care
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Transfer of Care to other Providers
Transfer of Care at the ED
Specific Paramedic-Patient
Issues
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Advanced Directives & End of Life
Decisions
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Definitions
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Advanced Directive
Out of Hospital DNR
DNR vs. DNAR
Living Will
Durable Power of Attorney for Health Care
Patient Self-Determination Act
Specific Paramedic-Patient
Issues
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Advanced Directives & End of Life Decisions
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Living Will
Durable Power of Attorney for Health Care
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Texas Out of Hospital DNR
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Terminal Condition no longer required
Identification Devices
EMS requirements
Revocation
Can a Texas Paramedic honor an Advanced Directive
(other than a DNR)?
Specific Paramedic-Patient
Issues
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Advanced Directives & End of Life
Decisions
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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
Specific Paramedic-Patient
Issues
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Out of Hospital Death
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Initiation of care?
Many counties and cities require:
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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
Specific Paramedic-Patient
Issues
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Patient Confidentiality & Privacy
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“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
Specific Paramedic-Patient
Issues
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Patient Confidentiality & Privacy
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Colleague & Station Talk
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Must not identify the patient
Maintains confidentiality of specific medical info
Scene or Patient Photographs
EMS Radio Dispatch & Discussions
“Need to Know” Basis
Specific Paramedic-Patient
Issues
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Patient Confidentiality & Privacy
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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)
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?
Specific Paramedic-Patient
Issues
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Patient Confidentiality & Privacy
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Defamation
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“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
Operational Issues
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Equipment failure
Interaction with Law
Enforcement
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Crime Scenes
Preservation of
Evidence
Vehicle Operation
Medical Control
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Instructor Liability
Hospital Selection
Dispatch
Interfacility
Transfers
OSHA
Risk Management
Operational Issues
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Equipment Failure
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Product Liability
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Design flaw in ventilator
Failure on part of owner/operator
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No backup battery for defibrillator
Operational Issues
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Interaction with Law Enforcement
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Crime Scenes
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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
Operational Issues
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Interaction with Law Enforcement
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Evidence Preservation
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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
Operational Issues
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Vehicle Operation
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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)
Operational Issues
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Vehicle Operation
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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?
Operational Issues
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Medical Control Issues
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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
Operational Issues
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Instructor Liability
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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
Operational Issues
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Hospital Selection
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Paramedic & Medical Control decision
Closest & Appropriate Facility
Written policies or guidelines
What is the closest & most appropriate facility? What
does this mean?
Operational Issues
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Dispatch Issues
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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
Operational Issues
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Interfacility Transfer Issues
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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?
Operational Issues
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OSHA & Risk Management
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OSHA generally not applicable to government
employees
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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”
Documentation
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Patient Confidentiality
Securing/Sharing/Requests for
Information
Protected Classes
Quality & Effectiveness
Documentation
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Patient Confidentiality
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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
Documentation
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Securing/Sharing/Requests for
Information
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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?
Documentation
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Protected Classes
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In some states, patient information related
to sexually transmitted diseases or other
specific diseases has become protected as
confidential
Washington state
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Can not refer to HIV/AIDS or STD status in
report without consent
Then, only with a clear need to know
Documentation
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Quality & Effectiveness
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Complete soon after the patient contact
Be thorough and accurate
Be honest, objective and factual
Caution with abbreviations
Maintain confidentiality
Do not alter
Documentation
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Quality & Effectiveness
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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?
Summary
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There are many legal
issues surrounding the
EMS environment
The paramedic should
attempt to keep up-todate with local legal
requirements
Ignorance is not
acceptable!
Suggested Reference
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Cohn, B. M. Azzara, A. J. Legal Aspects
of Emergency Medical Services. W. B.
Saunders Company. 1998