Medical, Legal, and Ethical Issues

Scope of practice vs. standard of care

Two ideas are easy to confuse and are tested precisely because of it. Scope of practice is the legal boundary of what an EMT may do. It is defined by state and regional legislation and varies from one location to another, so the same skill may be within scope in one state and outside it in the next. Standard of care is what a reasonably trained EMT would do in a similar situation, and it is the benchmark used in negligence claims. The distinction is worth fixing in your mind now: scope of practice is what you are allowed to do, while standard of care is what you should do, and how well you should do it.

Both have to be maintained after certification. You keep your skills by practicing them to mastery, and you keep your knowledge current through continuing education and recertification. Quality improvement is the other half of that work. After a call, critique your own performance and your crew's, and accept feedback as a way to improve the care you give. The spirit to bring to it is simple: hold yourself to the standard you would want for a member of your own family.

Consent

No competent patient can be treated without permission, and the form that permission takes depends on the patient's condition. The three types you will meet are set out below.

Table 4.1Consent

Capacity to consent, or to refuse, requires that the patient be an adult or an emancipated minor, mentally competent and not impaired by injury, illness or substances, and fully informed of the risks of refusing.

Refusal of care

A competent adult has the right to refuse care, even care you are certain they need. For that refusal to be valid, four conditions must all be met:

• The patient is a legal adult, or is otherwise legally authorized to refuse.
• The patient is mentally competent and oriented.
• The patient has been fully informed of the risks of refusing, in terms they understand.
• The patient makes the refusal without coercion.

The competence requirement carries a firm consequence: a patient intoxicated by alcohol or drugs cannot give a valid informed refusal.

When a patient does refuse, work through the situation rather than simply leaving. Try again to persuade them to accept transport, explaining the risks clearly, and consult medical direction. Satisfy yourself that the patient genuinely understands the consequences of the decision, then document thoroughly: your assessment findings, the exact risks you explained, and the patient's own words where you can capture them. Have the patient sign a refusal form and obtain a witness signature if one is available. Finally, leave the door open by encouraging them to call back if they change their mind or if their condition worsens.

DNR orders & POLST

A do not resuscitate (DNR) order is a legal document, typically signed by both the patient and a physician, stating that the patient has a terminal illness and does not want resuscitative efforts. It is one form of advance directive, meaning it is written and signed in advance of the event it governs. DNR orders vary in how specific they are. One might direct that resuscitation be attempted only if the arrest is witnessed and not if the patient is found already in arrest, which avoids resuscitating someone who may have sustained brain damage during an unwitnessed period of downtime.

Several related documents serve different purposes. Physician's Orders for Life-Sustaining Treatment (POLST) is broader than a DNR: it covers resuscitation together with other end-of-life preferences, such as artificial feeding and antibiotics, for use if the patient later cannot express their wishes. Some states allow physician assistants and advanced practice registered nurses to validate these forms rather than physicians alone, so check the rules where you work. A living will is a signed statement of preferences about long-term life support and comfort measures, and it typically applies to in-hospital situations rather than prehospital care. A health care proxy is a person the patient has named to make decisions on their behalf should they become unable to.

The critical decision rule

The rule to carry into a resuscitation decision is this: a family member's oral request alone, without a legal DNR document present, is not sufficient grounds to withhold resuscitation. It is better to be criticized or sued for attempting to save a life than for letting a patient die. Without an actual legal document in hand, provide care.

The reverse situation also occurs. If the family is under duress and wants a valid DNR ignored, so that they are asking for resuscitation despite a DNR on file, contact medical direction. The physician may need to speak with the family directly.

Ethical dilemmas — framework

Not every hard call is a clinical one. A colleague who hides a medication error, coming upon a crash after you have been drinking, a patient who confides involvement in a crime: these are genuine tests of judgment, and none of them has a protocol.

The general approach is to identify your options, weigh patient welfare, safety and legal obligation against the competing pressures, and choose the course that best protects the patient and upholds your professional and legal duty, even when that course is uncomfortable. Reporting a colleague's serious medication error is the clearest example. Patient safety, and honesty about the care actually given, supersede loyalty to a colleague.

Torts, negligence & legal concepts

A tort is a civil wrong, as opposed to a criminal act. One party's action causes harm to another, and the matter is resolved through civil liability and a lawsuit rather than criminal prosecution.

Negligence is the tort an EMT is most likely to face, and it has 4 required elements. All of them must be present for a claim to succeed:

1. Duty to act. You had an obligation to provide care.
2. Breach of duty. You failed to provide the expected standard of care.
3. Damages. The patient suffered actual harm.
4. Causation. Your breach of duty directly caused that harm.

Duty to act exists once you are on duty and dispatched, or in some jurisdictions once you have begun patient contact even while off duty. It varies by state and by employment status.

One doctrine sidesteps that four-part proof. Res ipsa loquitur, meaning "the thing speaks for itself," presumes negligence from the very nature of the injury or circumstance, without each element having to be proved individually. A surgical instrument left inside a patient is the classic example.

Three further terms describe specific wrongs. Abandonment is terminating care without ensuring that an equal or higher level of care continues, and without the patient's consent. Assault is placing a patient in fear of imminent harmful or unwanted contact. Battery is the actual unwanted physical contact, or care performed without consent.

Good Samaritan laws

Good Samaritan laws protect providers who voluntarily render emergency care in good faith and without expectation of payment, shielding them from liability for ordinary negligence. That protection does not extend to gross negligence or willful misconduct, and it is not total immunity: you can still be held liable for reckless or grossly negligent care.

Confidentiality & HIPAA

Confidentiality is the protection of patient information from unauthorized disclosure, and EMTs breach it more often by carelessness than by intent. The common ways are discussing patients in public spaces such as elevators, restaurants and social media; sharing patient information with unauthorized bystanders or the media; and leaving patient care reports or other patient information visible or accessible.

The Health Insurance Portability and Accountability Act (HIPAA) governs how patient health information may be shared. Information can generally be shared for treatment, payment and healthcare operations, which is what allows you to hand off to receiving hospital staff, but not for unrelated purposes without authorization.

Two related risks concern what you say about a patient rather than what you disclose. Slander is a spoken false statement that damages someone's reputation, and libel is the same thing in writing. Both are real legal risks if an EMT makes inaccurate, damaging statements about a patient that turn out to be false.

Special situations

Three situations come with their own rules, and each turns up regularly on calls.

• Medical identification devices. Bracelets, necklaces and wallet cards can inform your treatment decisions by revealing allergies, DNR status or chronic conditions. Use the information when it is present and relevant.
• Organ donor status. This does not change your resuscitation efforts for a living patient. It becomes relevant only after death has been determined.
• Safe haven laws. These allow a parent to surrender an unharmed newborn anonymously and legally, usually within a set number of days, at a designated safe location, without facing prosecution for abandonment.

Crime scenes

At a crime scene you have two jobs that can pull against each other, and the order between them is fixed: patient care always takes priority over evidence preservation. Scene safety comes before both, so do not enter until law enforcement confirms the scene is safe.

Within those limits, minimize disturbance to the scene wherever you can do so without compromising care. Avoid unnecessary movement of items, do not cut through bullet or knife holes in clothing but cut around them instead, and preserve footprints and other physical evidence where that is feasible.

Your observations matter as much as your care. Observe and document anything you see or hear, including what patients and bystanders say, because these observations can have real evidentiary value. Do not discuss the case with unauthorized parties such as the media or bystanders, and be prepared to appear as a witness in legal proceedings, where accurate and objective documentation will be what you rely on.