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INTRODUCTION

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Due to the difficulty in addressing the ethics and science of determining a patient's ability to participate in important medical decision making, it is important to review basic medical ethics principles. In order for these principles to be more fully understood, this chapter includes a number of clinical vignettes that are used to introduce principles and discuss their implementation in the prehospital environment.

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A 45-year-old man calls 9-1-1 after experiencing 15 minutes of substernal chest pain. On your arrival to the patient, he denies any complaints and his chest pain has subsided without intervention. You assess the patient and find he has an elevated blood pressure 200/100 and an ECG reveals NSR without ischemic changes. The patient reports feeling well and refuses further intervention or transport to the hospital. You feel the patient is at high risk for cardiac disease and believe he should be treated and transported. What do you do?

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OBJECTIVES

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  • Describe the principles of assessing a patient's capacity as defined by Applebaum and Grisso.

  • Discuss the prehospital assessment of capacity.

  • Discuss the basis for the right to refuse care.

  • Describe key elements of documentation during a patient refusal.

  • Describe indications for calling for law enforcement assistance.

  • Discuss state differences in laws regarding providing involuntary ­psychiatric treatment in the field.

  • Give examples of appropriate and inappropriate refusals.

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INFORMED CONSENT

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The medical legal concept of patient consent to medical treatment dates back to 1912 US case law in which Justice Cardoza writes: “Every human being of adult years and sound mind has a right to determine what shall be done with his own body.”1 This concept is further refined as informed consent by 1957 US case law with the addition of the duty to disclose information.2 This doctrine of informed consent relies on the principle of autonomy in which an individual has the right to self-determination, even if it results in harm. Although the medical, legal, and ethical principles of informed consent, medical decision-making capacity, and refusal of care have their foundation in medical care provided by physicians, they apply as well, and often with greater challenge, to prehospital ­providers: first responders, EMTs, and paramedics.

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In order for medical personnel to provide medical care, including assessment, evaluation, and transport of that patient by a prehospital provider, the patient must first consent to have that care provided. Many may assume the principle of informed consent does not apply to emergency medical services (EMS) because the care being provided is assumed to be in the case of an emergency, and therefore this exception to informed consent would apply. This idea of implied or emergent consent is often used by EMS but can only be assumed in a situation in which the care must be given to prevent death or serious injury. This emergency situation is not always the case in the ...

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