5.3 Legal, Ethical & HIPAA Considerations
Key Takeaways
Scope of practice is defined by state law and outlines the skills and procedures an EMT is legally allowed to perform; standard of care is the level of care a reasonably prudent EMT would provide in similar circumstances
Expressed consent is obtained from a competent adult who verbally or non-verbally agrees to treatment; implied consent applies to unconscious or mentally incapacitated patients when a life-threatening emergency exists
A competent adult has the right to refuse care even if the refusal may result in death; the EMT must ensure the refusal is informed and thoroughly document the encounter
Advance directives include DNR orders, POLST/MOLST forms, living wills, and healthcare power of attorney/proxy, and must be honored per local protocol
Negligence requires proving four elements: duty to act, breach of duty, causation (proximate cause), and damages (harm to the patient)
Abandonment occurs when an EMT terminates patient care without transferring to an equal or higher-level provider, and is both a legal and ethical violation
Good Samaritan laws provide limited liability protection to individuals who voluntarily provide emergency care in good faith and without gross negligence
EMTs are mandatory reporters for suspected child abuse, elder abuse, domestic violence, and certain communicable diseases or injuries (such as gunshot wounds) as required by state law
EMTALA requires hospitals with emergency departments to provide a medical screening exam and stabilizing treatment regardless of the patient's ability to pay
Scope of Practice vs. Standard of Care
| Concept | Definition | Set By |
|---|---|---|
| Scope of Practice | The range of skills, procedures, and medications an EMT is legally authorized to perform | State legislation, medical director |
| Standard of Care | The level of care a reasonably prudent EMT with similar training would provide in similar circumstances | Case law, protocols, training standards |
An EMT can be found negligent for acting outside the scope of practice OR for performing within scope but below the standard of care.
Types of Consent
Expressed Consent
- Obtained from a competent adult (alert, oriented, not impaired)
- Patient must be informed: told what you plan to do, potential risks, and alternatives
- Can be verbal ("Yes, please help me") or non-verbal (extending an arm for a blood pressure)
- Must be obtained before every treatment or procedure
Implied Consent
- Applies when a patient cannot give expressed consent due to:
- Unconsciousness
- Altered mental status
- Severe illness or injury making communication impossible
- Legal basis: a reasonable person would consent to life-saving treatment
- Applies only to emergency situations
Special Consent Situations
| Situation | Rule |
|---|---|
| Minors (under 18) | Parent or legal guardian must consent; implied consent applies in life-threatening emergencies when guardian is unavailable |
| Emancipated minors | May consent for themselves (married, military, court-declared, pregnant in some states) |
| Mental health holds | Law enforcement or physicians may authorize involuntary transport per state law |
| Intoxicated patients | If impairment prevents competent decision-making, implied consent may apply for emergencies |
Refusal of Care
A competent adult has the legal right to refuse any or all medical treatment, even if refusal may lead to death. To accept a refusal:
- Ensure the patient is competent: alert, oriented, not impaired by drugs/alcohol/injury
- Inform the patient of the risks of refusal, including potential outcomes up to and including death
- Encourage the patient to seek medical attention if symptoms worsen
- Ensure the patient understands they can call 911 again at any time
- Have the patient sign a refusal form (obtain a witness signature if possible)
- Document thoroughly: assessment findings, what was explained, patient responses, and that the patient appeared competent
NREMT Key Point: If there is any question about the patient's competence, err on the side of providing treatment and transport.
Advance Directives
| Directive | Description |
|---|---|
| DNR (Do Not Resuscitate) | Instructs providers NOT to perform CPR if the patient goes into cardiac arrest; must be a valid, signed document |
| POLST/MOLST | Physician/Medical Orders for Life-Sustaining Treatment -- a medical order (not just a wish) that covers CPR, intubation, artificial nutrition |
| Living Will | A legal document that expresses the patient's wishes regarding medical treatment if they become incapacitated |
| Healthcare Power of Attorney / Proxy | A designated person authorized to make medical decisions on behalf of the patient when the patient cannot |
- Always follow local protocol regarding advance directives
- If there is any doubt about the validity of a DNR, begin resuscitation
- A verbal DNR from a family member is generally not sufficient -- a written order is required
Negligence
To prove negligence, all four elements must be present:
| Element | Definition | Example |
|---|---|---|
| Duty to Act | The EMT had a legal obligation to provide care | On-duty EMT responding to a 911 call |
| Breach of Duty | The EMT failed to meet the standard of care | Failed to immobilize a suspected spinal injury |
| Causation | The breach directly caused or worsened the patient's harm | Patient's paralysis resulted from improper movement |
| Damages | The patient suffered actual harm (physical, emotional, financial) | Permanent disability, medical bills, pain and suffering |
Abandonment
Abandonment is the termination of care without the patient's consent and without transferring care to a provider of equal or higher certification. Examples include:
- Leaving a patient at the ED without giving a report to receiving staff
- Turning a patient over to a first responder when an EMT-level provider is required
- Going off duty while responsible for a patient
Good Samaritan Laws
- Provide limited legal protection to people who voluntarily render emergency care
- Apply when care is provided in good faith, without expectation of compensation
- Do not protect against gross negligence or willful misconduct
- Laws vary by state -- know your jurisdiction
- Generally apply to off-duty providers and bystanders, not on-duty EMS
Mandatory Reporting
EMTs are mandatory reporters and must report:
- Suspected child abuse or neglect
- Suspected elder abuse or neglect
- Domestic violence (varies by state)
- Certain injuries: gunshot wounds, stab wounds, suspicious burns
- Certain communicable diseases per state/local health department requirements
- Sexual assault (report to law enforcement per local protocol)
Failure to report suspected abuse can result in criminal charges and loss of certification.
EMTALA
The Emergency Medical Treatment and Labor Act (EMTALA) requires:
- Any hospital with an emergency department that participates in Medicare must provide a medical screening examination to anyone who presents
- If an emergency condition exists, the hospital must provide stabilizing treatment
- Patients cannot be turned away or transferred based on inability to pay
- Applies to the hospital, not directly to EMS, but EMTs should be aware of its existence
What is the key difference between scope of practice and standard of care?
Scope of practice is set by federal law; standard of care is set by state law
Scope of practice defines what an EMT may legally do; standard of care defines how well they must do it
Scope of practice applies only to paramedics; standard of care applies to all EMS providers
There is no practical difference; the terms are interchangeable
An EMT arrives to find a 45-year-old unconscious patient who was struck by a car. No family is present. Under what type of consent should the EMT provide care?
Expressed consent
Informed consent
Implied consent
Involuntary consent
Which of the following is required to prove negligence against an EMT?
Duty to act, breach of duty, and intent to harm
Duty to act, breach of duty, causation, and damages
Breach of duty, gross negligence, and patient complaint
Duty to act, patient complaint, and documentation failure
Which of the following are elements required to prove negligence against an EMT? (Select all that apply)
Select all that apply
Duty to act
Breach of duty
Causation (proximate cause)
Damages (harm to the patient)
Licensure in the state where the incident occurred
Intent to cause harm
Match each type of consent to its correct definition.
Match each item on the left with the correct item on the right
Implied consent
Expressed consent
Informed consent
A competent, alert 72-year-old patient with chest pain refuses transport to the hospital. The EMT should:
Contact law enforcement to force the patient to go
Call medical control and have them order the patient transported
Inform the patient of risks, have them sign a refusal, and document thoroughly
Leave the scene immediately since the patient does not want help
An EMT delivers a patient to the emergency department and leaves to respond to another call without giving a verbal report to the receiving nurse. This is an example of:
Negligence
Assault
Abandonment
Breach of confidentiality
Sections you finish are checked off in the contents.