legal obligation to treat?

[cbrons]

I am a first year medical student so I apologize if I am putting this inquiry into the wrong forum. I remember learning in a graduate school course some time ago that physicians have an obligation to treat people in emergency situations outside the hospital/office. For example, if someone has a heart attack on a plane, a physician who does not attend to the person could be in violation of the law?

I understand that if you do decide to help someone in an emergency situation, you must provide them with some acceptable standard of care. I am a little fuzzy about this, though... I have heard physicians who order drinks on airplanes just to have a plausible excuse not to treat people who suffer an acute MI mid-flight (presumably because they do not want to be sued if the person ends up dying). Anyway, can someone clear this up for me? Sorry if it is a little convoluted.

---

Members don't see this ad.

 

[smq123]

Moving to Topics in Healthcare.

 

[J-Rad]

Radiology focused, but still a nice general review of "good Samaritan" issues in medicine. Touches on your question.

Short answer: it depends on the state you're in.

 

[McGillGrad]

As I understand it, once you identify yourself and start treating, you have a certain level of obligation.

Seeing someone have a heart attack and walking away and only calling 911 is your right as a physician or nurse.

 

[Smurfette]

AFAIK, if you are in public (or on a plane), you do not have to come forward as a physician to help someone in distress and cannot be held liable for failing to act. Whether you can be held liable for treating someone and having something go badly for the patient, I've heard conflicting information. I assume it varies by location or situation.

 

[dpmd]

My understanding is that Germany has legal obligation to treat for health care providers, but you know that kind of thing would never fly in the US. As a country we seem to not like to be told we have to do things. Hell, even in the hospital I don't think we have a legal obligation to treat in an emergency (excluding EM providers, and taking care of your own patients). How often do you run to a code if you aren't part of the designated code team (and the room number isn't one where your patient might be)?

 

[Kphrogg]

In the majority of states, you do not have a legal obligation to treat someone in an emergency. In the U.S., we generally do not require people to aid others toward whom they have no preexisting relationship, e.g., parent-child, doctor-patient, etc.

If the person requiring assistance has no reason to rely on you for help, you have no obligation. Additionally, if bystanders are not reasonably relying on you to help the person, you have no obligation. However, if you announce that you are a doctor, and people refrain or delay in seeking help as a result, then you have a legal obligation to provide care. Additionally, if you start to administer care, you are legally obligated to continue until someone better qualified intervenes (this is generally true for all people, however, not just doctors).

 

[ccfccp]

The only state I am aware of in which one has a legal obligation to treat is Vermont. This was originally initiated because there weren't very many people and/or doctors in Vermont, and so if someone was having a heart attack, the next nearest doc may be 25-50 miles away.

Also, if a physician has a pre-exisiting physician/patient relationship with the patient, it could be pretty easily argued the physician has a fiduciary responsibility to treat. I'm not sure whether that would hold up in court. If there is no such relationship, however, there is no legal mandate.

The most common place in which one has a "legal obligation to treat" is the emergency department. Technically EMTALA only mandates a "medical screening exam," but by that point, you've done about 75% of the work anyway, so most people just finish the treatment.

 

[loveoforganic]

Doesn't EMTALA also mandate treatment of any imminently life threatening state as well?

 

[docB]

So this isn't a total I'll address the OP's question. In general in the US (I don't know anything about VT but I have no reason to doubt ccfccp) you don't have to come forward in an emergency in the field (or on a plane, etc.). There are various libertarian and practical reasons for this. Practically it's not all that helpful to have health care providers with little training or experience in EMS, EM or another generalist field to come forward and get in the way. It's almost always better for them to call 911 and stay on the phone.

If you DO step up then you will be covered under (or held to) the Good Samaritan standard (see J-Rad's post). Basically it says you can not be FOUND liable ("found" meaning you could get sued but you should win, still a mess) if you had no expectation of payment and you didn't do anything that was grossly negligent.

Interestingly that "expectation of payment" bit gets tricky. The rumors go that airplanes used to give free ticket vouchers to docs who would help on planes. Someone got successfully sued under the theory that they did get "paid" and were therefore not covered under the Good Sam law. I don't really know if this is true or not but the prevailing wisdom now is that you should be careful about accepting anything for helping out.

Hell, even in the hospital I don't think we have a legal obligation to treat in an emergency (excluding EM providers, and taking care of your own patients). How often do you run to a code if you aren't part of the designated code team (and the room number isn't one where your patient might be)?

In the hospital physicians who are on the call list are obligated to see patients when consulted. The call list is actually a formal thing and is reportable to the government. If someone refuses to see a patient and they have to be transferred the transferring hospital and physician are obligated by law to name the physician who failed to respond so that the receiving hospital can file a complaint. Getting hit with an EMTALA complaint is a huge deal with fines that start at $50K and a possibility of the physician and the hospital losing their Medicare/Medicaid participation, i.e. going out of business.

Doesn't EMTALA also mandate treatment of any imminently life threatening state as well?

EMTALA mandates the treatment of any "emergent medical condition" (which they don't define) but this is only inside a hospital that meets certain criteria such as participates in Medicare/Medicaid, has an ER, the patient has presented for treatment. It does not apply outside the hospital (actually beyond 200 yards from the hospital property) and has no bearing on a Good Samaritan type situation out in the field.

EMTALA is an insanely complicated topic. Every term has a lot of definitions and case law that muddles it. You can see this from my quip about EMTALA's mandate actually extending beyond the boundaries of the hospital property. First it's complicated, second a rule like that means someone somewhere got burned on someone who wasn't even on their property yet.

Here's a good overview thread with links about EMTALA.

Here's a good thread with EMTALA discussions.

 

[loveoforganic]

Thanks for the info!

The rumors go that airplanes used to give free ticket vouchers to docs who would help on planes.

Just to add anecdote to this, gf's dad (dentist, but prior EMS with current BLS/ACLS) was given a ticket voucher (albeit this was quite some time ago) for helping out with a medical issue on a plane.

 

[RabbMD]

Thanks for the info!



Just to add anecdote to this, gf's dad (dentist, but prior EMS with current BLS/ACLS) was given a ticket voucher (albeit this was quite some time ago) for helping out with a medical issue on a plane.

I helped out on a case a 2 years ago on a plane, got like 10,000 free airline miles is all.

 

[cbrons]

Radiology focused, but still a nice general review of "good Samaritan" issues in medicine. Touches on your question.

Short answer: it depends on the state you're in.

So this isn't a total I'll address the OP's question. In general in the US (I don't know anything about VT but I have no reason to doubt ccfccp) you don't have to come forward in an emergency in the field (or on a plane, etc.). There are various libertarian and practical reasons for this. Practically it's not all that helpful to have health care providers with little training or experience in EMS, EM or another generalist field to come forward and get in the way. It's almost always better for them to call 911 and stay on the phone.

If you DO step up then you will be covered under (or held to) the Good Samaritan standard (see J-Rad's post). Basically it says you can not be FOUND liable ("found" meaning you could get sued but you should win, still a mess) if you had no expectation of payment and you didn't do anything that was grossly negligent.

Interestingly that "expectation of payment" bit gets tricky. The rumors go that airplanes used to give free ticket vouchers to docs who would help on planes. Someone got successfully sued under the theory that they did get "paid" and were therefore not covered under the Good Sam law. I don't really know if this is true or not but the prevailing wisdom now is that you should be careful about accepting anything for helping out.



In the hospital physicians who are on the call list are obligated to see patients when consulted. The call list is actually a formal thing and is reportable to the government. If someone refuses to see a patient and they have to be transferred the transferring hospital and physician are obligated by law to name the physician who failed to respond so that the receiving hospital can file a complaint. Getting hit with an EMTALA complaint is a huge deal with fines that start at $50K and a possibility of the physician and the hospital losing their Medicare/Medicaid participation, i.e. going out of business.



EMTALA mandates the treatment of any "emergent medical condition" (which they don't define) but this is only inside a hospital that meets certain criteria such as participates in Medicare/Medicaid, has an ER, the patient has presented for treatment. It does not apply outside the hospital (actually beyond 200 yards from the hospital property) and has no bearing on a Good Samaritan type situation out in the field.

EMTALA is an insanely complicated topic. Every term has a lot of definitions and case law that muddles it. You can see this from my quip about EMTALA's mandate actually extending beyond the boundaries of the hospital property. First it's complicated, second a rule like that means someone somewhere got burned on someone who wasn't even on their property yet.

Here's a good overview thread with links about EMTALA.

Here's a good thread with EMTALA discussions.

Thanks, this is really good information

 

[ccfccp]

On cursory google search, this is the best I could come up with about the Vermont thing. Second paragraph of answer: http://www.internalmedicinenews.com...-tan/blog/good-samaritan-acts/3a069dcd8c.html

I'm sure there's better info somewhere, but I'm post-call and don't have the energy to find it.

 

[LeemerDO]

Much as it sounds admirable, there is unfortunately precedence that has been set in California regarding a good samaritan that was successfully sued in court. Therefore, even though the law on the books say that you're covered, the court decisions say otherwise, and there is now a BIG drawback to even lift a finger, let alone, identifying yourself to being a doctor and rendering assistance. It's a sad state of affairs all because of one misguided judgement in court.

Here is the case if people are interested:

http://abcnews.go.com/TheLaw/story?id=6498405&page=1

 

[hithere3387]

Much as it sounds admirable, there is unfortunately precedence that has been set in California regarding a good samaritan that was successfully sued in court. Therefore, even though the law on the books say that you're covered, the court decisions say otherwise, and there is now a BIG drawback to even lift a finger, let alone, identifying yourself to being a doctor and rendering assistance. It's a sad state of affairs all because of one misguided judgement in court.

Here is the case if people are interested:

http://abcnews.go.com/TheLaw/story?id=6498405&page=1

The story to which the link you provided directs indicates that medical workers are still immune to legal recourse following an incident. I'm not certain that blanket immunity from prosecution is a reasonable standard when the "Good Samaritan" doesn't have training to deal with emergent situations. Anyway, the woman described in this story hasn't lost the suit, merely the motion to dismiss. This might be one of those instances in which the subtle mind of a judge is required.

 

[loveoforganic]

The court ruled 4-3 that only those administering medical care have legal immunity, but not those like Torti, who merely take rescue action. The justices said that the perceived danger to Van Horn in the wrecked car was not "medical."

Be right back letting a kid get hit by a train

Now 26, she has returned to her home in Minneapolis and is confined to a wheelchair. "She is ruined for life," said Hutchinson.

All those paraplegics just waiting for the day to end themselves, right?

And it's her coworker she was supposedly cordial with noless. Some people don't cope well

 

[hurdlepup]

Of note: in America, you can sue anyone for anything.

 

[loveoforganic]

Also of note, the judge does not have to allow the case

 

[paintballdoc]

Agree with docB's assessment (mostly). If you ever decide to help out as a Good Sam, never accept any form of payment. Do not accept upgrade to first class if on plane, a milkshake if at McDonalds, etc (you get the idea). If you accept a form of payment, you WILL NOT be covered under Good Sam rules if a liability claim is filed.

In terms of being totally protected under Good Sam laws, that is not always the case. I attend the Legislative Committee for my state. Bear in mind I am not a lawyer, but our state lawyer who is also instrumental in interpreting the PPACA (so he has some definite insight) told us physicians, that in KY, the Good Sam laws specifically does not apply to physicians. So be careful if getting involved.

I hate to admit that I have decided to never help in an emergency if I am unknown. I live in a small town, so there may be some instances I may be "required" to help. I have decided that the deck is stacked against us and NOTHING will interfere with my ability to provide for my children and wife.

 

[paintballdoc]

One other thought. I had a neighbor come upon a wreck a few years ago. He is a Rad Tech with years of experience. The lady complained of some neck pain but he was concerned that the car was smoking and may blow. He decided to take the chance and move her without a neck stabilizer but he kept her cervical spine in place with his hands. Needless to say, the car did not blow and she was okay.

I just imagined what would have happened if the scenario involved me and I made the same, reasonable decisions. However, she developed an unstable C-spine and became quadriplegic. If you think Good Sam laws would protect you, as a physician, good luck. Scenarios like this occur all the time and cannot control what may happen. So be prepared.

 

[hithere3387]

Agree with docB's assessment (mostly). If you ever decide to help out as a Good Sam, never accept any form of payment. Do not accept upgrade to first class if on plane, a milkshake if at McDonalds, etc (you get the idea). If you accept a form of payment, you WILL NOT be covered under Good Sam rules if a liability claim is filed.

In terms of being totally protected under Good Sam laws, that is not always the case. I attend the Legislative Committee for my state. Bear in mind I am not a lawyer, but our state lawyer who is also instrumental in interpreting the PPACA (so he has some definite insight) told us physicians, that in KY, the Good Sam laws specifically does not apply to physicians. So be careful if getting involved.

I hate to admit that I have decided to never help in an emergency if I am unknown. I live in a small town, so there may be some instances I may be "required" to help. I have decided that the deck is stacked against us and NOTHING will interfere with my ability to provide for my children and wife.

Could you go into a little more detail regarding the lack of protection for physicians in Kentucky? I'm a resident, and I don't know anything about it.

 

[YouISee]

Agree with docB's assessment (mostly). If you ever decide to help out as a Good Sam, never accept any form of payment. Do not accept upgrade to first class if on plane, a milkshake if at McDonalds, etc (you get the idea). If you accept a form of payment, you WILL NOT be covered under Good Sam rules if a liability claim is filed.

In terms of being totally protected under Good Sam laws, that is not always the case. I attend the Legislative Committee for my state. Bear in mind I am not a lawyer, but our state lawyer who is also instrumental in interpreting the PPACA (so he has some definite insight) told us physicians, that in KY, the Good Sam laws specifically does not apply to physicians. So be careful if getting involved.

I hate to admit that I have decided to never help in an emergency if I am unknown. I live in a small town, so there may be some instances I may be "required" to help. I have decided that the deck is stacked against us and NOTHING will interfere with my ability to provide for my children and wife.

It's America failing and falling. Don't hate to admit the truth of our new society. Now any unsuccessful loser can make it to the top without trying. Opportunists are everywhere. Patients are now just customers. Stop feeling bad for them. Don't let empathy (once valued in our society) cloud your judgement.

All you can hope for is raising your kids not to be these kind of people and having them always watch their own backs. And also setup a good asset protection scheme. This is the only time I guess you would want to work with the Sith a.k.a lawyers who have training in something completely useless which is interpreting garbage.

 

[TR MD]

Decades ago, in certain jurisdictions, doctors were able to put "MD" on their vehicle licence plates as part of the offical registration - it was a prestige thing. However, it got itresome as then, they were expected to stop and help pedestrains in visible medical stress. So, they became anonymous drivers like others, and did not bother to stop.

We do not live in an ideal world. I would be most reluctant to identify myself in a situation where I knew absolutely nothing about this stranger's medical history for fear that my lack of intimate knowledge might lead to complications that otherwise might not occur and there could be a substantial judgment against me one day. Without a signed waiver with informed consent, I would not get involved (other than phoning 911 or something similar). Life is harsh and not kind.

 

[Blackdogue]

My understanding is that Germany has legal obligation to treat for health care providers, but you know that kind of thing would never fly in the US. As a country we seem to not like to be told we have to do things. Hell, even in the hospital I don't think we have a legal obligation to treat in an emergency (excluding EM providers, and taking care of your own patients). How often do you run to a code if you aren't part of the designated code team (and the room number isn't one where your patient might be)?

Apart from Germany, in many other European countries and Australia you can get in trouble for not helping, from what I read.