This issue was raised on the Facebook page of the Paramedic Observer but I’m taking the liberty of commenting on it here.

The question asked was ‘What liability is there to respond to MedicAlert?’ (though it may be better to phrase it as ‘What obligation is there to respond to MedicAlert?’)  The post then linked to two New Zealand articles:

The articles relate two cases where a medic alert warning was ignored.  In one a child is reported to have had a life threatening condition that was recorded on the medic-alert bracelet that was ‘ignored’; another involved a patient with a known allergy to an antibiotic that was administered even though the allergy was recorded on the medic alert bracelet.  The story does say that the 80 year old patient ‘died six days later’ but it’s not clear if that was due to the allergic reaction or some other condition or complication.

According to the website of the Medic-Alert Foundation (Australia) they offer a number of services.  Apart from the familiar medic-alert jewellery that can record relevant conditions they also provide, amongst other things, a ‘24/7 hotline for emergency services and healthcare personnel to call’ and a ‘Wallet sized emergency health card’.

So what is the obligation upon health professionals, paramedics, nurses and doctors, to take account of this information?

The answer is quite simple.  The whole point of patient or health care is to advance the interests of the person in need of care.  Respect for the principle of autonomy means that the person, first and foremost who knows what is in the person’s best interests is the person themselves.    It is for this reason that people must be involved, to the extent that they can be, in their health care decision making and why ‘except in cases of emergency or necessity, all medical treatment is preceded by the patient’s choice to undergo it’ (Rogers v Whitaker (1992) 175 CLR 479, [14] (Mason CJ, Brennan, Dawson, Toohey and McHugh JJ)).   The principle of necessity justifies treatment that is necessary and in the patient’s best interests when the patient cannot consent, but not where treatment is contrary to the known wishes of the person (In Re F  [1990] 2 AC 1).

When deciding what treatment is reasonably necessary and in a patient’s best interests, the patient’s history is clearly relevant.   Whether it’s to determine what treatment they want or what treatment is indicated, or contra-indicated, in the particular circumstances.

A bracelet or necklace, whether it’s provided by Medic-Alert or just something they’ve had engraved at the local jeweller’s is one way of communicating that history.   In Malette v Shulman [1990] 67 D.L.R. (4th) 321, the plaintiff carried a card that said she did not want a blood transfusion under any circumstances.    The card was ‘the only way possible to notify doctors and other providers of health care, should she be unconscious or otherwise unable to convey her wishes (p 428)’ and via the card she ‘She gave notice to the doctor and the hospital, in the only practical way open to her’ of her wishes (p 431).  (See also ‘Medical tattoos offer important health information’ March 3, 2012  )

A medic-alert bracelet may have advance directives (like Do Not Resuscitate) or something else such as recording a prior condition or allergy.  In any case, like Ms Malette’s card, it is the only way to communicate with health care professionals if the patient cannot speak for themselves.    There can be no justification for ignoring it.   A doctor who needs to treat a person could not ignore their advice that they are allergic to a particular drug, regardless of whether that information is given verbally or via a bracelet.  A doctor or paramedic who is faced with a semi-conscious patient and who has to try to determine what is the cause of their symptoms cannot sensibly ignore a bracelet that reports the person is epileptic, or diabetic or has any other condition that might be relevant.   That of course won’t say that the reason for their current condition is that pre-existing illness but in forming a diagnosis and treatment plan, the health professional should at least consider it.

All of this assumes the medic-alert bracelet is located.  If it is not found and there is no negligence in not finding it, eg it’s in the person’s pocket rather than on their wrist so a ‘noes-to-toes’ examination does not turn it up, then of course it can’t be considered. Where it is being worn however, at some point it should be located and once that is done it can’t sensibly be ignored.

If the information is ignored, so the patient receives treatment that is contra-indicated but which would have been avoided if the information on the bracelet had been acted upon, or if diagnosis is delayed again because the information is ignored and if the wrong or delayed treatment can be shown to have made the patient’s long term outcome worse, then there could be liability in negligence.    For registered health professionals there could also be issues of professional discipline because one would have to ask whether it is satisfactory professional conduct to ignore the patient’s advice and history when the person has gone to significant lengths to attempt to communicate that relevant information to their health care professionals.