Consent The granting of permission to treat a patient. You must have consent before treating a patient. Patient must be competent to give or withhold consent

ConsentConsentThe granting of permission to treat a patient.

You must have consent before treating a patient.

Patient must be competent to give or withhold consent.

Types of consentTypes of consent

Expressed (Informed)

Implied

Informed ConsentInformed Consent

Consent based on full disclosure of the nature, risks, & benefits of a procedure.

Must be obtained from every competent adult before treatment.

In most states, a patient must be > 18 years of age to give/withhold consent.

In general, a parent or guardian must give consent for children.

Expressed ConsentExpressed ConsentVerbal, nonverbal, or written communication by a patient who wishes to receive treatment.

The act of calling for EMS is generally considered as an expression of the desire to receive treatment.

You must obtain consent for each treatment provided.

Expressed ConsentExpressed ConsentMust be obtained from every conscious, mentally competent adult.

A mentally competent adult is older than the legal age & able to make an informed decision

For the consent to be informed, the patient must be made aware of all risks, benefits, & consequences of the care provided and any alternatives to care

A patient must express their consent verbally or with affirmed gesture

Implied ConsentImplied Consent

Refers to circumstances where verbal or written consent is not possible but considers that a reasonable person would want & expect ER treatment to be rendered

Implied ConsentImplied ConsentConsent for treatment that is presumed for a patient who is mentally, physically, or emotionally unable to give consent.

It is assumed that a patient would want life-saving treatment if able to give consent.

Also called ER doctrine.

True ERTrue ER

True ER: exists when a person will either die or have a permanent injury if not treated immediately

Consent is considered implied; the person, if awake or able, would want care

Can be used with children under 18

Special Consent Situations Special Consent Situations

Minors (Usually a person < 18 years of age).

Consent must be obtained from a parent or legal guardian.

Mentally incompetent adultConsent must be obtained from the legal guardian.

Special Consent Situations Special Consent Situations

For minors & mentally incompetent adults . . .

If a parent or legal guardian cannot be found, treatment may be rendered under the doctrine of implied consent.

Minors & ConsentMinors & ConsentParent or legal guardian gives consent.

In some states, a minor can give consent.

Depending on age & maturity

Emancipated minors (married, armed services, parents)

Teachers & school officials may act in place of parents.

Minors & ConsentMinors & ConsentIf true ER exists, and no consent is available:

Treat the patient.

Consent is implied.

Involuntary ConsentInvoluntary ConsentConsent for treatment granted by a court order.

Most commonly encountered with patients who must be held for mental-health evaluation or as directed by law enforcement personnel who have the patient under arrest.

May be used on pts whose disease threatens a community at large.

Emancipated MinorEmancipated Minor Person < 18 years of age who is:

Married

Pregnant

A parent

A member of the armed forces

Financially independent living away from home

Emancipated minors may give informed consent.

Withdrawal of ConsentWithdrawal of ConsentA patient may withdraw consent for treatment at any time, but it must be an informed refusal of treatment.

RefusalsRefusalsConscious, alert adults with decision-making capacity:

Have the right to refuse treatment

Can withdraw from treatment at any time

Even if the result is death or serious injury

Places burden on EMT to clarify need for treatment

If EMS providers touch & provide ER care to a patient without consent, they leave themselves open to charges of assault & battery

RefusalsRefusalsBefore you leave a scene where a patient, parent, or caregiver has refused care:

Encourage them again to allow care.

Ask them to sign a refusal of care form.

Document all refusals on a patient care report form.

A witness is valuable in these situations.

An example of a “Release-from-Liability” form

An example of a “Release-from-Liability” form

Refusal of ServiceRefusal of ServiceNot every EMS run results in the transportation of the patient to the hospital.

ER care must always be offered to the patient, no matter how minor the injury or illness.

If a Patient Refuses (1 of 4)If a Patient Refuses (1 of 4)

Is the patient legally permitted to refuse care?

Make multiple, sincere attempts to convince the patient to accept care.


Make sure the patient is informed in his or her decision.

Consult with on-line medical direction.


Have the patient & a disinterested witness sign a release-from-liability form.

Advise the patient he or she may call again for help.


Attempt to get someone to stay with the patient.

Document the entire situation thoroughly.

Some EMS systems have checklists for procedures to follow when a patient refuses care.

Some EMS systems have checklists for procedures to follow when a patient refuses care.

Bledsoe et al., Essentials of Paramedic Care: Division 1© 2007 by Pearson Education, Inc. Upper Saddle River, NJ

Legal Complications

Related to Consent

Legal Complications

Related to Consent

Legal Complications Related to Consent (1 of 4)


AbandonmentThe termination of the paramedic-patient relationship without assurance that an equal or greater level of care will continue

AbandonmentAbandonmentTermination 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



Assault Act of unlawfully placing a person in apprehension of immediate bodily harm without his or her consent

Battery The unlawful touching of another person without his or her consent



False imprisonment The intentional & unjustifiable detention of a person without his or her consent or other legal authority



Reasonable forceThe minimal amount of force necessary to ensure that an unruly or violent person does not cause injury to himself, herself, or others

Advanced DirectivesAdvanced Directives

Advance directives specify treatment should the patient become unconscious or unable to make decisions.

A do not resuscitate (DNR) order is an advance directive that gives permission not to resuscitate.

“Do not resuscitate” does not mean “do not treat.”

DNRDNRMust Contain

Name of patient

Name and signature of physician

Effective date

The words “Do Not Resuscitate”

Evidence of consentSignature of patient

Signature of legal guardian

Signature of POA (Power of Attorney)

Revocation -DNRRevocation -DNRIf the order is physically destroyed or verbally rescinded by the physician who signed the form or person who gave written informed consent to the order (Patient, or POA)A member of the immediate family is present and requests initiation of resuscitation contrary to the written order

When in doubt call home…

Living WillLiving WillIllinois law allows terminally ill patients to instruct their health care provider on their treatment in near death experiences

Technical requirements make these documents impractical in the field and are not honored in the field

Power of AttorneyPower of AttorneyA legal document signed by the patient that names a specific person to act on behalf of the patient in making medical decisions, should the patient not be able to do so

If the patient is alert & able to communicate, the healthcare agent has no authority

Malpractice SuitsMalpractice Suits

Burns: from hot water, heating pads, lights, malfunctioning equipment, too strong solutions, showers, baths

Falls: out of bed, while ambulating, due to wet floors, defective equipment, over-sedation

Failure to observe & take appropriate action: refusing to answer call lights, orthopedic injuries, not taking VS, leaving patients alone

Examples for Malpractice SuitsExamples for Malpractice Suits


Medication & injection errors

Dispensing meds as an EMT

Mistaken identity: meds, procedures, surgery

Failure to communicate: not informing MD of patient problems; poor shift reports; inability to reach MD

Abandonment: leaving alone a patient who should not be left alone—double shifts?


Loss or damage to patient property: dentures, clothing, hearing aids

Things left in patients during surgery: res ipsa loquitur— the thing speaks for itself

Lack of informed consent: permission must beVoluntary (no coercion)

Informed (person must clearly understand choices & what is to be done)

Physician’s job to get informed consent

Legal ConceptsLegal Concepts

Good Samaritan law: written to encourage healthcare professionals to help in ER situations

Reduces the professional liability when responsible care is used

Care given must be in the professional’s scope of practice & training

Rests on the concept of “implied consent”


Statute of limitation: a time period after which a malpractice suit cannot be filed

Generally 2 years after the discovery of injury

In children, up to age 21


Expert witness: a person called to provide special information or opinions in cases that require special study or experience

Usually an instructor, physician, or nursing supervisor, EMT…

Can give opinions—usually testimony only allows facts

Suit-Prone PatientsSuit-Prone Patients

Very demanding

Very critical of all aspects of the care experience

Very dependent

Critical of other EMTs

Has filed a lawsuit before

Suit-Prone HCPsSuit-Prone HCPs

Insensitive to patient needs

Undereducated

Overconfident

Authoritarian

Inflexible

Protection Against LawsuitsProtection Against Lawsuits

Maintain good medical records

Establish good relationships with patients

Keep your skills current

Assess the patient frequently for changes

Maintain professional manner

Avoid making statements that may admit fault


Don’t criticize other professionals

Stay within your scope of practice

Be definite about instructions

Take extra precautions with telephone orders

Monitor the care of those you supervise

Check the condition of healthcare equipment you are using


If in doubt, stop!

Watch for adverse outcomes (medications, treatments, etc.)

If you suspect a lawsuit, notify your insurance carrier immediately

Never tell a patient you have malpractice insurance

If a suit is filed, don’t talk to anyone but your lawyer

Malpractice InsuranceMalpractice Insurance

Two types of policies:Claims-made: protect you only while your policy is in effect

Can purchase “tails” that expand the policy

Usually a little cheaper

Occurrence policies: protect against any claims that occurred during the policy period no matter when it was made

Documents

Consent The granting of permission to treat a patient. You must have consent before treating a patient. Patient must be competent to give or withhold consent