Consent is required for every conscious adult before care can be started. If a patient refuses, that can be extremely illegal. Decision-making capacity/competence is the ability of a patient to understand the information you are providing, coupled with the ability to process that information and make an informed choice regarding medical care. Things to consider are intellectual capacity impaired by mental limitation or any type of dementia; age; drugs or alcohol; significant pain; significant injury that can distract from a more serious problem; hearing or visual problems; language barrier; do they understand what you are saying. The right of a patient to make decisions concerning his or her health is known as patient autonomy.
There are three types of consent: expressed consent, implied consent, and involuntary consent. Expressed consent – if you ask and the patient agrees. Informed consent – must tell information on what is being done and get consent – valid if given verbally. Document or have someone witness them. Implied consent – when a person is unconscious or otherwise incapable of making decisions, law assumes that a patient would consent to care and transport to a medical facility if he or she were able to do so. Head injuries, drugs and alcohol also fall under this category, or mentally impaired. This may result in legal proceedings and a medicolegal judgment, which should be supported by your best efforts to obtain consent and a thoroughly documented run report. Law allows close relatives or next of kin to give consent for an injured person who is unable to do so, and you should make efforts to get consent from them before treating based on implied consent; however, if life-threatening, treatment should not be delayed. When the person regains consciousness, implied consent is no longer valid. Involuntary consent – mentally ill, developmentally delayed, or who are in a behavioral (psychological) crisis is complicated. Not able to give informed consent. Law enforcement is able to give consent in cases of incarcerated or has been placed under arrest. However, a prisoner who is conscious and capable of making decisions does not necessarily surrender the right to make medical decisions and may refuse care.
In certain circumstances you may need to use forcible restraints. Need of medical treatment and is combative; in some states only police can forcibly restrain. Can only be used when at risk to self or others. Only if a behavioral disorder or medical condition. Verbal de-escalation should always be attempted prior to considering physical restraints. Once applied they should not be removed. Consider calling for ALS backup to provide chemical pharmacologic restraint as this may be safer than physical restraint depending on the situation.
When the patient refuses treatment or transport the EMT has certain roles and obligations. Adults who are conscious, alert, and appear to have decision-making capacity have the right to refuse treatment or withdraw from treatment at any time even if it may result in death. Patients who have attempted suicide or convey suicidal intent should not be regarded as having normal mental capacity. When you are not able to obtain consent you must get a signature and a witness. Parents that refuse care for a minor may be charged with neglect later.
Communication between you and the patient is considered confidential and generally cannot be disclosed without permission from the patient or a court order. Protected health information – health information and any information that can be used to identify the patient. PHI – may be disclosed for purposes of treatment, quality improvement, and payment. Legally required in cases of abuse to take action, but only the minimum amount of information should be given. Avoid TikTok that violates HIPAA, but the general public can do it.
Do Not Resuscitate order: you may be placed in a very difficult position. A competent patient is able to make rational decisions about his or her well-being. An advance directive is a written document that specifies medical treatment for a competent patient – health care directive. Some patients may have a durable power of attorney for health care or health care proxy. DNR does not mean do not treat.
Death is defined as the absence of circulatory and respiratory function, brain death provision as well. Then the questions arise as to whether to begin basic life support; if no DNR, if the body is still intact and there are no definitive signs of death, initiate emergency medical care. Hypothermia – a person should not be considered dead until warm and transitioned. When unclear best to begin CPR.
Presumption signs of death:
Unresponsiveness to painful stimuli
Lack of a carotid pulse or heartbeat
Absence of chest rise and fall
No deep tendon or corneal reflexes
Absence of pupillary reactivity
No systolic blood pressure
Profound cyanosis
Lowered or decreased body temperature
Decapitation
Dependent lividity: blood settling to the lowest point of the body causing discoloration of the skin
Algor mortis – cooling of the body
Rigor mortis – stiffening of body muscles caused by chemical changes
Putrefaction – depending on temperature conditions, this occurs sometime between 40 and 96 hours after death
Scope of practice is where you are legally able to provide for the patient. Your medical director defines the scope of practice by developing protocols and standing orders. If you carry out procedures for which you are not authorized that can lead to criminal negligence. Duty to act includes the following: you are charged with emergency medical response, your service or department’s policy states that you must assist in any emergency. Once you respond you have a duty to act. If you see a crash and you respond you must continue to provide competent care until an equal or higher medical authority assumes care of the patient, but you are not required to respond.
Negligence is the failure to provide the same care that a person with similar training would provide. There is a breach of duty when an EMT does not act within an expected and reasonable standard of care. Damages occur when the patient is harmed. Causation – there must be a relationship between the breach of duty and the damages suffered by the patient. This is often called proximate causation. Dropping the patient during lifting causing a fracture. If an EMT has a duty and breaches it, causing harm, the EMT and the medical director can be sued for negligence if that breach of duty was the direct cause of the patient’s injury. Res ipsa loquitur – occurs if a patient was hurt in your care due to a mistake or slip, was unconscious, and sued later. All forms of negligence come under the general category known as torts. Torts are simply defined as civil wrongs. Abandonment – you are not allowed to leave until someone who is equally or more qualified takes over – a passerby. Assault is providing care to someone who doesn’t wish to be supported. False imprisonment, refuses consent and wants to be let out of the rig. It is also unlawfully placing a patient in fear of bodily harm. A theory that may be used when the conduct of the person being sued is alleged to have occurred in clear violation of a statute.
If an action or procedure is not recorded on the written report, it was not performed. Compiling and maintaining accurate reports and records of all events and patients. Required to report abuse, injury during the commission of a felony, drug-related injuries, childbirth, scene of a crime, or the deceased. Attempted suicide, domestic violence, sexual assault or rape.
Ethics is the philosophy of right and wrong, of moral principles and of ideal professional behavior. Keep the best interests of your patients at the forefront of your conduct and decision making, conduct yourself in a manner that is consistent with the standards of your profession. Morality is a code of conduct that can be defined by society, religion, or a person, affecting character and conscience and the definition of right versus wrong. The entire field of ethics known as bioethics has evolved. Ethical challenges occur, but stay true to your moral code because rules and regulations are there for a reason, and that reason is to save lives.
EMT OATH
Be it pledged as an EMT, I will honor the physical and judicial laws of God and man. I will follow that regimen which, according to my ability and judgment, I consider for the benefit of patients and abstain from whatever is deleterious and mischievous, nor shall I suggest any such counsel. Into whatever homes I enter, I will go into them for the benefit of only the sick and injured, never revealing what I see or hear in the lives of men unless required by law.
I shall also share my medical knowledge with those who may benefit from what I have learned. I will serve unselfishly and continuously in order to help make a better world for all mankind.
While I continue to keep this oath unviolated, may it be granted to me to enjoy life, and the practice of the art, respected by all men, at all times. Should I trespass or violate this oath, may the reverse be my lot.
So help my God.
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