An EMT professional must essentially work morally, ethically and in compliance with laws, now this isn’t always as easy and in some cases discrepancies between ethical behavior and federal law can occur.
In any case, EMTs must be aware of what is legal and act within the law, protecting both themselves and the patient.
An understanding of the basic concepts and how to act in each case is really important, starting with the most basic, consent.
CONSENT
Consent to care from the patient is needed for the EMT to establish physical contact with the patient in order to treat them.
There are different types of consent starting from expressed which can be oral or some other indication such as extending their arm when a EMT asks “Can I measure your blood pressure?”, an arm extension towards the EMT would mean consent is being given. Informed consent is when the patient is given information, has understood it and agrees to care with it.
There is not always an ideal situation where consent can be given, therefore sometimes consent must be implied this is when the EMT will assume the person would have liked something to be done and proceed acting in that way.
In some cases, consent is involuntary, this can occurr in instances where acting without consent is necessary in order to avoid danger, this can occur when law enforcement is involved, and restraint is needed.
Consent can cause an ethical dilemma in the case of minors, as such, they cannot technically consent nor refuse care, meaning only their parents or someone in the scene who is “in charge” of the minor such as a teacher can give or refuse it. This means, in some cases which can be life or death, parents or the guardian refuse lifesaving care, the ethical duty for the EMT would be acting to save the minor’s life but could later on be facing legal consequences. In these cases, the correct way to act would be communication and persuasion, backed up with information on the risks and benefits, if it failed, it must be documented that this was the parent’s decision and not abandonment.
Emancipated minors are to be taken into account as well as they are able to agree or refuse to care due to the fact that they are emancipate. There are some situations however that cause confusion such as a minor who is also a parent, are they considered emancipated? If not, they are able to give or refuse consent on behalf of their child but not for themselves?
PATIENT INFORMATION
Following HIPAA, EMTs have access to EHRs but cannot disclose any information that can be used to identify the patient by third parties. They cannot share information regarding the patient’s history, findings or their treatment.
In some states patient provider confidentiality is applied in these cases and therefore even if documents are legally required, they can still remain in custody and undisclosed.
In other states, only HIPAA is applied and so, this information may be used in cases such as teaching or legally when assault of a minor is suspected or regarding public health such as in the case of a possible pandemic.
Information disclosure can be incidental for example when two patients are being transported in the same ambulance due to shortage of vehicles.
CRIMINAL ACTIONS
There may be some cases where the EMT is required to report something such as: abuse and assault, child abuse or neglect, elder abuse, domestic violence, communicable diseases or animal bites. In these cases, disclosure of patient information may even be mandatory.
ADVANCED DIRECTIVES
This is something that must be taken into account as in all cases, the patient’s wishes must be respected. This means knowing whether he/she is DNR, if they have a durable power of attorney, if there is a living will etc. This is confusing in some cases where the family’s wishes do not correspond to those of the patient, they may be in the scene pleading to the EMT to do something to save the patient but the latter is DNR. Furthermore, how ethical is it to not act if the patient is DNR, can this be considered assisted suicide in dome cases where the patient can be suicidal?
FUTILITY OF CARE
According to the protocol, when a patient isn’t breathing and is still warm, CPR must be performed even if the EMT knows the patient is already deceased. Meaning EMTs are put in danger due to fast driving to get to the hospital and upon arrival, the patient will be declared dead by a physician. All the while, giving the family and friends a false hope. Is this necessary?
In order to illustrate the importance of this conflict, here is a real case:
Life vs. Law: When the Mandates Are at Odds
By Jay Weaver
In the world of EMS, as in all areas of healthcare, law and ethics sometimes collide. I witnessed such a conflict recently while working as a paramedic for the city of Boston.
The patient was an 11-year-old girl. We found her at home late at night, gasping for air. She understood English, but the only other person in the house, her stepfather, did not. Unable to communicate the girl’s history, he presented us with a stack of medical records nearly three inches thick.
The papers revealed a heartbreaking tangle of medical and social issues. The patient had never known her father. Her mother had been murdered just two weeks before. Since the girl was related to her stepfather only through marriage, her mother’s death had left her a ward of the state. She continued to live with her stepfather, but he had no legal authority to make medical decisions on her behalf.
The story got worse. One year earlier, the girl had been diagnosed with lung cancer. It had metastasized to her brain, and the hospital suspended chemotherapy after a doctor declared her condition terminal. Since the girl was still a minor, and therefore too young to legally accept or reject care, an attorney for the state’s social service agency had gone to court seeking clarification of her resuscitation status.
The judge who’d inherited the case met with the girl privately. For more than an hour, he posed questions about life, sickness, medical procedures and death. During this conversation, the girl indicated that she didn’t want to be resuscitated in the event of respiratory or cardiac arrest. Despite her young age, the judge felt that she was mature
enough to understand the consequences of such a decision. On this basis, he issued an order prohibiting resuscitation.
The night we were called to the girl’s house, I found the judge’s order attached to her medical documents. Its language was clear, and there could be no question that it applied to us. The judge had addressed it to “all healthcare providers, including EMS professionals.”
The girl was in severe respiratory distress, capable of saying just a few words at a time. We placed her on a stretcher and wheeled her to the ambulance, intending to administer bronchodilators as soon as we could set up a nebulizer. Just as we were about to lift her inside, she looked up at me and, with a terrified expression, whispered, “Please don’t let me die.”
Then she stopped breathing. A pair of EMTs had been sent on the call with us. One of them reached for a bag-valve mask. He said, “You want me to ventilate her, right?”
My partner deferred to me. “What does that court order mean?” he asked. “Is that the same thing as a Do Not Resuscitate order?”
Being a lawyer as well as a paramedic, I knew it was not the same thing at all. Under the laws of most states, a Do Not Resuscitate (DNR) order can be rescinded by the patient at any time. A court order, on the other hand, can be rescinded only by the judge who issued it, or by a panel of judges in a court of appeals. I held in my hand a document that had been based on the wishes of a patient, but issued by a judge. We had a legal obligation to follow it.
Still, I couldn’t ignore the patient’s plea. She was a little girl who, just moments before, had begged me not to let her die. It would be a simple matter to comply with her wish. I could ventilate her, and that would keep her alive.
Unfortunately, it would also break the law.
I took the bag-valve mask from the EMT and applied it to the girl’s face. I ventilated her all the way to the hospital.
She did not regain consciousness, but her heart kept beating, and she remained alive, just as she’d requested.
In the emergency department, a nurse continued the ventilation while an administrator called the hospital’s lawyer at home. Stop the resuscitation, the lawyer advised. You’re breaking the law. A doctor ordered the nurse to stop. The girl’s heart slowed. After a few minutes, it stopped entirely. The doctor pronounced her dead.
Some time later, I asked a judge for an informal legal opinion on this matter. “Oh, you absolutely broke the law,” he told me. “When you ventilated that girl, you were in contempt of court. The judge who wrote the order could have fined you or put you in jail. But no judge in this state would impose sanctions for doing what you did. It may have been illegal, but from a moral standpoint, it was the right thing to do.”
I think about that girl often. I present this case when lecturing to paramedic students. Asked what they would do in the same situation, they always say they would resuscitate her. Faced with the same choices again, I would too.
For those of us in EMS, conscience sometimes trumps the law.