Transcript Chapter 3

3: Medical, Legal, and Ethical Issues
Cognitive Objectives
(1 of 3)
1-3.1 Define the EMT-B’s scope of practice.
1-3.2 Discuss the importance of DNR orders (advance
directives) and local and state provisions regarding
EMS application.
1-3.3 Define consent and discuss the methods of
obtaining consent.
1-3.4 Differentiate between expressed and implied
consent.
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Cognitive Objectives
(2 of 3)
1-3.5 Explain the role of consent of minors in providing
care.
1-3.6 Discuss the implications for the EMT-B in patient
refusal of transport.
1-3.7 Discuss the issues of abandonment, negligence,
and battery and their implications for the EMT-B.
1-3.8 State conditions necessary for the EMT-B to have
a duty to act.
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Cognitive Objectives
(3 of 3)
1-3.9 Explain the importance, necessity, and legality of
patient confidentiality.
1-3.10 Discuss the considerations of the EMT-B in issues
of organ retrieval.
1-3.11 Differentiate the actions that an EMT-B should
take in the preservation of a crime scene.
1-3.12 State the conditions that require an EMT-B to
notify law enforcement officials.
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Affective Objectives
1-3.13 Explain the role of EMS and the EMT-B regarding
patients with DNR orders.
1-3.14 Explain the rationale for the needs, benefits, and
usage of advance directives.
1-3.15 Explain the rationale for the concept of varying
degrees of DNR.
• There are no psychomotor objectives for this chapter.
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Medical, Legal, and Ethical Issues
• Scope of practice
– Defined by state law
– Outlines care you can provide
– Further defined in protocols and standing orders
– Authorized through online and off-line medical
direction
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Standard of Care (1 of 2)
• Standard imposed by local custom
– Often based on locally accepted protocols
• Standard imposed by the law
– May be imposed by statutes, ordinances,
administrative guidelines, or case law
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Standard of Care (2 of 2)
• Professional or institutional standards
– Recommendations published by organizations and
societies
– Specific rules and procedures of your service or
organization
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Standards Imposed by States
• Medical Practices Act
– Exempts EMT-Bs from licensure requirements
• Certification
– Process of evaluating and recognizing that
EMT-B has met certain predetermined
standards
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Duty to Act
• Individual’s responsibility to provide patient care.
• Responsibility to provide care comes from either
statute or function.
• Legal duty to act begins once an ambulance responds
to a call or treatment is initiated.
• No legal duty to act when off duty
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Negligence
Failure to provide the same care that a person with
similar training would provide
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Negligence Determination (1 of 2)
• Duty
– Responsibility to act reasonably based on standard
of care
• Breech of duty
– Failure to act within expected and reasonable
standard of care
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Negligence Determination (2 of 2)
• Damages
– Physical or psychological harm created in a
noticeable way
• Cause
– Existence of reasonable cause and effect.
• All four must exist for negligence to apply.
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Abandonment
• Termination of care without patient’s consent
• Termination of care without provisions for continued
care
• Care cannot stop unless someone of equal or higher
training takes over
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Consent
• Expressed consent
• Implied consent
• Minors
• Mentally incompetent adults
• Forcible restraints
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Assault and Battery
• Assault
– Unlawfully placing a person in fear of immediate
bodily harm without consent
• Battery
– Unlawfully touching a person
• Some states have grades of assault, no battery
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Refusal of Treatment
• Mentally competent adults have the right to refuse
care.
• Patients must be informed of risks, benefits,
treatments, and alternatives.
• EMT-B should obtain a signature and have a witness
present, if possible.
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Good Samaritan Laws and Immunity
• Good Samaritan
– Based on the principle that you should not be liable
when assisting another in good faith
• Immunity
– Usually reserved for governments
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Advance Directives
• Specifies medical treatments desired if patient is
unable to make decisions
• Do not resuscitate (DNR) orders
– Patients have the right to refuse resuscitative
efforts.
– Require a written order from one or more
physicians
– When in doubt, begin resuscitation.
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Ethical Responsibilities
• Make the physical/emotional needs of the patient a
priority.
• Practice/maintain skills to the point of mastery.
• Critically review performances.
• Attend continuing education/refresher programs.
• Be honest in reporting.
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Confidentiality
• Information received from or about a patient is
considered confidential.
• Disclosing information without permission is
considered a breach of confidentiality.
• Generally, information can only be disclosed if the
patient signs a written release.
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HIPAA
• Safeguards patient confidentiality.
• Limits EMS providers from obtaining follow-up
information.
• Releases health information only with patient’s
permission.
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Records and Reports
• Complete documentation is a safeguard against legal
complications.
• If an action or procedure is not recorded, courts
assume it was not performed.
• An incomplete or untidy report is considered evidence
of incomplete or inexpert care.
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Special Reporting Requirements (1 of 2)
• Abuse of children, elderly, and spouse
• Injury during the commission of a felony
• Drug-related injury
• Childbirth
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Special Reporting Requirements (2 of 2)
• Infectious disease exposure
• Crime scene
• Deceased
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Physical Signs of Death
• Death is the absence of circulatory and respiratory
function.
• If the body is still warm, initiate care.
• If hypothermia is present, initiate care.
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Presumptive Signs of Death
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Unresponsive to painful stimuli
Lack of pulse or heartbeat
Absence of breath sounds
No deep tendon or corneal reflexes
Absence of eye movement
No systolic blood pressure
Profound cyanosis
Decreased body temperature
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Definitive Signs of Death
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Obvious mortal injury
Dependent lividity
Rigor mortis
Putrefaction (decomposition of body)
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Medical Examiner Cases
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DOA
Unknown cause of death
Suicide
Violent death
Poisoning
Accidents
Suspicion of criminal action
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Special Situations
• Organ donors
• Medical identification
insignia
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Review
1. You arrive at the scene of an elderly lady complaining
of chest pain. In assessing her, she holds her arm out
for you to take her blood pressure. This is an example
of:
A. implied consent.
B. informed consent.
C. expressed consent.
D. emergency consent.
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Review
Answer: C
Rationale: Expressed consent (also called actual
consent) is when the patient authorizes you to provide
treatment and transport, either verbally or nonverbally.
For example, a patient who holds out his or her arm to
allow you take a blood pressure is nonverbally giving
you expressed consent.
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Review
1. You arrive at the scene of an elderly lady complaining of chest
pain. In assessing her, she holds her arm out for you to take her
blood pressure. This is an example of:
A. implied consent.
Rationale: Implied consent is limited to life-threatening emergencies
and is appropriate when a person is unconscious and/or
delusional.
B. informed consent.
Rationale: Informed consent is when the patient has been told of the
specific risks, benefits, and alternative treatments.
C. expressed consent.
Rationale: Correct answer. It is also know as actual consent.
D. emergency consent.
Rationale: This does not exist as a form of consent.
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Review
2. Which of the following is an example of abandonment?
A. An EMT-B leaves the scene after a competent adult
has refused care.
B. An EMT-B transfers care of a patient to an emergency
department nurse.
C. An EMT-Intermediate transfers care of a patient to an
EMT-Paramedic.
D. A First Responder is transferred patient care from an
EMT-Intermediate.
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Review
Answer: D
Rationale: Abandonment occurs when patient care is
terminated without the patient’s consent or when care
is transferred to a provider of lesser training and level
of certification.
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Review
2. Which of the following is an example of abandonment?
A. An EMT-B leaves the scene after a competent adult has refused
care.
Rationale: Mentally competent adults have the right to refuse
treatment or withdraw from treatment at any time.
B. An EMT-B transfers care of a patient to an emergency
department nurse.
Rationale: An EMT-B can transfer care to someone of equal or
higher medical authority.
C. An EMT-Intermediate transfers care of a patient to an EMTParamedic.
Rationale: An EMT-I can transfer care to someone of equal or
higher medical authority.
D. A First Responder is transferred patient care from an EMTIntermediate.
Rationale: Correct answer
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Review
3. Your unit is the first to arrive at the scene of an injured
person. As you approach the residence, you hear
screaming and the sound of breaking glass. You
should:
A. quickly enter the house and provide emergency care.
B. retreat to a safe place and notify law enforcement.
C. request police assistance and then enter the
residence.
D. carefully enter the house and identify yourself as an
EMT.
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Review
Answer: B
Rationale: Never enter a scene when signs of violence
(eg, screaming, breaking glass) are present. Retreat to
a safe place and notify law enforcement at once. You
should enter the scene only after law enforcement
have arrived and deemed is secure.
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Review
3. Your unit is the first to arrive at the scene of an injured person. As
you approach the residence, you hear screaming and the sound
of breaking glass. You should:
A. quickly enter the house and provide emergency care.
Rationale: Never enter a scene when signs of violence
(eg, screaming, breaking glass) are present.
B. retreat to a safe place and notify law enforcement.
Rationale: Correct answer
C. request police assistance and then enter the residence.
Rationale: Never enter a scene when signs of violence
(eg, screaming, breaking glass) are present.
D. carefully enter the house and identify yourself as an EMT.
Rationale: Never enter a scene when signs of violence
(eg, screaming, breaking glass) are present.
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Review
4. Failure of the EMT-B to provide the same care as
another EMT-B with the same training is called:
A. libel
B. slander
C. negligence
D. abandonment
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Answer: C
Rationale: An EMT-B could be held liable for negligence
if he or she fails to provide the same care as another
EMT-B with the same training provide in the same
situation. For example, if an EMT-B fails to give
oxygen to a patient with shortness of breath (an
intervention that is clearly indicated), he or she may be
held liable for negligence.
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Review
4. Failure of the EMT-B to provide the same care as another EMT-B
with the same training is called:
A. Libel
Rationale: Libel is making a false statement in a written form that
injuries a good person’s name.
B. Slander
Rationale: Slander is verbally making a false statement that injuries
a good person’s name.
C. Negligence
Rationale: Correct answer
D. Abandonment
Rationale: Abandonment is the abrupt termination of contact with a
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patient.
Review
5. An 8-year-old boy was struck by a car, is unconscious, and
is bleeding from the mouth. As you begin to provide care, a
police officer tells you that he is unable to contact the
child’s parents. You should:
A. continue to treat the child and transport as soon as
possible.
B. cease all treatment until the child’s parents can be
contacted.
C. continue with treatment only if authorized by medical
control.
D. only provide airway management until the parents are
contacted.
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Answer: A
Rationale: The child in this scenario is critically-injured
and requires immediate treatment and transport;
waiting until his parents are contacted wastes time and
increases his chance of a negative outcome. If you are
unable to contact a minor’s parents or legal guardian,
you should proceed with care based on the law of
implied consent.
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Review
5. An 8-year-old boy was struck by a car, is unconscious, and is
bleeding from the mouth. As you begin to provide care, a police
officer tells you that he is unable to contact the child’s parents.
You should:
A. continue to treat the child and transport as soon as possible.
Rationale: Correct answer
B. cease all treatment until the child’s parents can be contacted.
Rationale: If a true emergency exists, then consent is implied.
C. continue with treatment only if authorized by medical control.
Rationale: If a true emergency exists, then consent is implied.
D. only provide airway management until the parents are contacted.
Rationale: If a true emergency exists, then consent is implied.
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Review
6. An advanced directive is:
A. a set of specific guidelines that clearly defines the
different types of consent.
B. a formal list that defines by state law whether a patient
has decision-making capacity.
C a written document that specifies the care you should
provide if the patient is unable to make decisions.
D. a verbal order given to you by a dying patient's family
regarding whether treatment should be provided.
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Review
Answer: C
Rationale: An advanced directive is a written document
signed by the patient and a witness that specifies the
medical care that should be provided if the patient
loses decision-making capacity (ie, he or she is no
longer deemed competent).
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Review
6. An advanced directive is:
A. a set of specific guidelines that clearly defines the different types of
consent.
Rationale: An Advanced Directive specifies the specific care a patient
will receive and does not address any type of consent.
B. a formal list that defines by state law whether a patient has decisionmaking capacity.
Rationale: An Advanced Directive document has already determined
that a patient was competent to make decisions when the
document was created and signed.
C. a written document that specifies the care you should provide if the
patient is unable to make decisions.
Rationale: Correct answer
D. a verbal order given to you by a dying patient's family regarding
whether treatment should be provided.
Rationale: An Advanced Directive is a written order that defines the48
patient’s medical decisions.
Review
7. Which of the following patients is competent and can
legally refuse EMS care?
A. A confused young female who states that she is the
president
B. A man who is staggering and states that he only drank
three beers
C. A conscious and alert woman who is in severe pain
from a broken leg
D. A diabetic patient who has slurred speech and is not
aware of the date
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Review
Answer: C
Rationale: A patient who is of legal age (18 in most
states), is conscious, and is alert to person, place,
time, and event, likely has decision-making capacity
and can legally refuse EMS care. However, patients
who are confused, possibly intoxicated, or delusional
are not capable of making a rationale decision;
therefore, you should provide care based on the law of
implied consent.
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7. Which of the following patients is competent and can legally
refuse EMS care?
A. A confused young female who states that she is the president
Rationale: You must assess whether this patient’s mental condition
is impaired.
B. A man who is staggering and states that he only drank three
beers
Rationale: You must assess whether this patient’s mental condition
is impaired.
C. A conscious and alert woman who is in severe pain from a
broken leg
Rationale: Correct answer
D. A diabetic patient who has slurred speech and is not aware of the
date
Rationale: You must assess whether this patient’s mental condition
is impaired.
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Review
8. You are treating a patient with an apparent emotional
crisis. After the patient refuses treatment, you tell him
that you will call the police and have him restrained if
he does not give you consent. Your actions in this
case are an example of:
A. assault.
B. battery.
C. negligence.
D. abandonment.
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Review
Answer: A
Rationale: Unlawfully placing a person in fear of
immediate bodily harm (ie, having him restrained)
without his consent constitutes assault. Unlawfully
touching a person without his or her consent
constitutes battery.
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Review
8. You are treating a patient with an apparent emotional crisis. After
the patient refuses treatment, you tell him that you will call the
police and have him restrained if he does not give you consent.
Your actions in this case are an example of:
A. assault.
Rationale: Correct answer
B. battery.
Rationale: Battery is the unlawfully touching of a person. This
includes care without consent.
C. negligence.
Rationale: Negligence is failure to provide the same care that a
person with similar training would provide.
D. abandonment.
Rationale: Abandonment is the unilateral termination of care without
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the patient’s consent.
Review
9. The EMT-B has a legal duty to act if he or she is:
A. off duty and witnesses a major care accident.
B. a volunteer, is on duty, and is dispatched on a call.
C. paid for his or her services, but is not on duty.
D. out of his or her jurisdiction and sees a man choking.
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Review
Answer: B
Rationale: The EMT-B—paid or volunteer—has a legal
duty to act if he or she is on duty and is dispatched on
a call, regardless of the nature of the call. If the EMT-B
is off duty and/or out of his or her jurisdiction, he or
she has a moral obligation to act, but not necessarily a
legal one.
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Review
9. The EMT-B has a legal duty to act if he or she is:
A. off duty and witnesses a major care accident.
Rationale: This is a moral obligation to act and not a legal one.
B. a volunteer, is on duty, and is dispatched on a call.
Rationale: Correct answer
C. paid for his or her services, but is not on duty.
Rationale: Whether paid or volunteer, the EMT-B must be on duty.
D. out of his or her jurisdiction and sees a man choking.
Rationale: This is a moral obligation to act, and not a legal one.
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Review
10. Which of the following statements about records and
reports is FALSE?
A. Legally, if it wasn't documented, it was not performed
B. A complete, accurate report is an important safeguard
against legal problems
C. An incomplete or untidy patient care report is
evidence of incomplete or inexpert emergency medical
care
D. Your patient care report does not become a part of the
patient’s hospital record because your treatment was
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provided outside the hospital
Review
Answer: D
Rationale: One of your most important safeguards
against legal problems is a complete, accurate report;
if it wasn’t documented, it wasn’t done! Furthermore,
an incomplete or untidy patient care report (PCR)
suggests incomplete or inexpert medical care. The
PCR becomes a part of the patient’s hospital medical
record; even though your treatment was provided
outside the hospital, the PCR ensures continuity of
care in the hospital.
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Review
10. Which of the following statements about records and reports is
FALSE?
A. Legally, if it wasn't documented, it was not performed
Rationale: True. If it was not written, then it was not performed.
B. A complete, accurate report is an important safeguard against
legal problems
Rationale: True. Most the important safeguard against legal
problems is a complete, accurate report.
C. An incomplete or untidy patient care report is evidence of
incomplete or inexpert emergency medical care
Rationale: True. An incomplete or untidy report equals incomplete or
inexpert emergency care.
D. Your patient care report does not become a part of the patient’s
hospital record because your treatment was provided outside
the hospital
Rationale: Correct answer
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