Paramedic 1.23 – Medical/Legal and Ethics: Advanced Directives

In this module, we will take a brief look
at advanced directives and their applicability within the EMS environment. Once completed with this module, you should
be able to explain advanced directives and how they impact patient care. This module addresses legalities related to
advanced directives. In providing this information, nothing in
this presentation should be construed as legal advice. Rather, the information provided is merely
a broad overview of this legal subject as denoted within the national paramedic educational
standards. Please be aware that every state has different
laws that impact EMS agencies and providers, and these laws may change over time by application
of legislative action or court decisions. Federal, state, and local laws and other legal
provisions not discussed within this presentation may also impact EMS agencies and providers. Additionally, information that was current
or applicable at the time this presentation was produced may not be at the time you are
watching this presentation and new laws may have been added as well. Lastly, the legal topics and doctrines discussed
within these presentations are not the totality of all laws that apply to EMS agencies and
providers. There are numerous other laws and provisions
that impact diverse aspects of providing EMS. If you or any other EMS provider has questions
related to the laws that apply within the realm of providing EMS, additional guidance
and assistance should be obtained from a licensed attorney within your area who has subject
matter expertise in the specific area of law in question. In an earlier module we talked about consent
and a patient’s right to personal autonomy and self-determination in their healthcare
decisions. Over time, our society has begun to recognize
the impact of better healthcare, longer life expectancies, and medical advances on end-of-life
decisions. We now have technology to keep a person’s
body and organs functioning even if they are considered brain dead with no reasonable probability
of recovery. There are some cancers where the treatment
is arguably worse than disease itself, and some have even argued that we treat dying
pets with more respect and dignity in their last hours than some people. To euthanize a dying pet is considered humane,
yet a dying relative in considerable pain with no hope of recovery from a serious ailment
or disease is often denied the opportunity to “die with dignity.” Invariably, end-of-life decisions and the
debate related to taking affirmative steps to terminate a life or allow someone to die
without having to go through unwanted medical procedures are not the purview of this particular
presentation. Rather, we need to objectively look at the
laws as they are written so that EMS providers know how to function when faced with a patient
who does not desire heroic measures to prolong his or her life. To this end, Congress passed the Patient Self-Determination
Act in 1990 to ensure patients’ rights to self-determination in health care decisions
be communicated and protected. Under the law, certain healthcare organizations
(such as hospitals, skilled nursing facilities, home health agencies, hospice programs, and
health maintenance organizations) must provide patients with a written summary of their health
care decision-making rights and the facility’s policies with respect to recognizing advanced
directives. These same entities must also ask the patient
about advanced directives and update that information within the patient’s medical
record. Covered organizations must train their staff
on these requirements and it is prohibited for them to discriminate against patients
based upon whether or not they have an advance directive. Notice that the word “organizations” is
used throughout this description. That is because the requirements of the Patient
Self-Determination Act do not apply to individual physicians. A critical facet of the Patient Self-Determination
Act is that it relies upon the laws of each state to define the legal requirements for
advanced directives. Thus, the implementation of advance directives
by any particular healthcare organization are defined by individual state laws. With that being said, the three most common
advance directive instruments for conveying a patient’s wishes to healthcare providers
are living wills, power of attorneys for healthcare, and do not resuscitate orders. A living will is simply a document that is
designed to go into effect if the person completing the document has a debilitating incident that
prevents him or her from conveying his or her wishes to healthcare providers. The document is typically idle without any
impact or effect until a specific type of medical event occurs, at which point it can
then provide legal direction to healthcare providers as to what the patient’s wishes
are related to his or her care. A durable power of attorney, specifically
one related to healthcare, is a document that gives someone else the authority to make healthcare
decisions for the individual in the event of incapacity. The presumption is that the person named as
having the healthcare power of attorney for the person will act in the individual’s
best interests and try to carry out his or her wishes in the event difficult healthcare
decisions must be made. (This particular power of attorney for healthcare
is different from a general or financial power of attorney that gives the person control
over the impacted party’s financial and other legal affairs.) Lastly, most EMS providers are very aware
of do not resuscitate orders that apply when a patient enters a pulseless, non-breathing
state. Some states, like Wisconsin, require the patient
to be wearing a do-not-resuscitate bracelet to convey his or her do-not-resuscitate wishes
to EMS providers. Some states give medical control the ability
to accept other types of do-not-resuscitate orders as well. Additional legal provisions often recognize
that a DNR order is not the same as committing suicide (which could impact life insurance
or other related benefits or contractual relationships). Legal liability protection may also be afforded
to EMS providers who follow DNR orders in good faith. Unfortunately, many of these laws are not
necessarily written with EMS providers in mind and complicated scenarios are too easy
to identify. In Wisconsin, for instance, DNR orders are
valid for EMS providers only when the patient is wearing a statutorily-mandated bracelet. If an EMS crew responds to a nursing home
where the bracelet is attached to the patient’s chart and not the patient him or herself,
they should technically begin CPR, even if they know it is against the patient’s wishes. Another shortcoming of the Wisconsin law is
that there is no guidance on what to do if a person has an out-of-state order. Children under the age of 18 are also not
eligible to receive a DNR bracelet, even though there are cases within formal healthcare environments
where children are no-codes given a serious and unfortunate terminal illness or condition. With more of these children receiving in-home
hospice care, an inadvertent 911 call for that child could put the EMS crew in a very
difficult position. Given significant differences from state-to-state
in the legal provisions governing end-of-life decisions and advanced directives, EMS students
and providers are strongly encouraged to seek more information on the topic through additional
education and training, from their own EMS agency, an attorney in their jurisdiction
who is familiar with EMS and end-of-life issues, or any combination of these resources. For the time being, however, you should now
be able to generally explain advanced directives and how they impact patient care within the
EMS environment. This presentation was prepared by Waukesha
County Technical College in Pewaukee, Wisconsin and is distributed with an attribution, non-commercial,
share alike 4.0 international Creative Commons license. Copyright 2019, Waukesha County Technical
College. For information on WCTC’s numerous fire
and EMS educational offerings, please visit us online at

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