Today’s question revisits the role of paramedics in giving honest advice to patients, including advice that they do not need to go to hospital. To a large extent I think it has been answered before – see Transport everyone or act as a professional? A question for paramedics (May 6, 2013) – but it’s worth returning too.  Today’s correspondent says:

Within the Queensland Ambulance Service we use the acronym VIRCA to validate that the decision to not transport a patient is safe for the patient, the paramedic and the organisation.

The components of VIRCA are V – Voluntary, I – Informed, R – Relevant, C – Capacity and A – Advice.

My question to you relates to the component of informed.

When I attend a patient and I provide them with my clinical findings, which may be along the lines that – with the limited tools that I have, I have been unable to find anything life threatening at this time. However, the only option for a more detailed assessment with a higher degree of assessment will be at a hospital emergency department. And then the discussion will generally follow my view that (generally) radiography, pathology and other assessments are generally required to form an accurate diagnosis.

I recently had dealings with a case where a member of the public made a complaint because it was their view that the paramedics should have been trying “to talk the patient into going to hospital” and this got me thinking. If the paramedics provide very clear information that the assessment is not all inclusive, and there may be underlying conditions which cannot be identified in a thorough ambulance assessment and the patient does not appear affected by any illicit drugs or alcohol and they are provided with the finding that the person should attend hospital for further assessment but they continue to refuse and the patient was left with discharge advice to call the ambulance service again if there is any change in the patient’s condition, or they become concerned in any way.

If all these factors have been fulfilled – where does the component of informed end? I have heard some colleagues say that they tell every person who refuses treatment and/or transport, that they may die. Now that could be true of any member of the population, but it does not seem reasonable or responsible in most instances. Do you believe that a line exists between the component of informed – and the thought that we should be talking patients into being assessed at hospital?

With registration for paramedics looming, I am particularly cautious of the cohort of patients who refuse treatment/transport against advice and the possible ramifications in the event that the patient does deteriorate.

I’d welcome your thoughts and advice.

Paramedics are, and certainly with registration will be expected to act as professionals. That means exercising judgment and acting in the best interests of your patient. A paramedic who says to every patient ‘who refuses treatment and/or transport, that they may die’ is not acting as a professional.  They are not acting as a professional because they are putting their own fear ahead of the needs of the patient.  They are not acting in the patient’s best interest.

Nor are they allowing the patient to make an informed choice.  It’s true the patient may die. In fact the patient will die.  It would not be wrong to say to every patient who refused transport ‘you are going to die’ but it’s not informative, particularly if the paramedic thinks there is no reason to suspect that they are going to die soon or from any condition that is currently showing symptoms.

In the days when ambulance services are encouraging people only to call triple zero in an emergency and empowering paramedics to exercise judgment on whether to transport or not, a person who tries to scare patients is not exercising that judgment and is not contributing to a holistic health service.

To be an informed refusal the patient must be competent, have the information upon which to make a decision (including the limitations that the person giving the information faces) and the refusal must cover the circumstances.  If the paramedic’s honest view is that there is no indication that the person needs to go to hospital then that too is part of the information the person needs in order to make an informed choice.

In the case involving the death of Stacy Yean (see No adverse comments regarding paramedics following death of a woman in Ballarat, Victoria (April 3, 2017):

The paramedics took two sets of observations, 10 minutes apart, and concluded that Ms Yean ‘may have a “gastric bug” and [her] presentation did not mandate transport to hospital’.   They offered to take her to hospital but did advise that the hospital was busy and she was likely to face a long delay in being seen.   In light of the advice, Ms Yean declined the offer of transport to hospital…

Ms Yean died later that evening though the exact cause of death was never determined.  The family were necessarily and understandably distraught that the paramedics, in their view talked Ms Yean out of going to hospital.  The paramedics on the other hand, said Ms Yean refused their offer of transport.  The Coroner said neither view was correct. The Coroner said (emphasis in original):

I find the interpretation put on the issue of transportation by both parties, AV and the family interesting. Ms Handley [one of the paramedics] states Ms Yean “refused” the offer of transportation. I would have thought a more appropriate interpretation would be “declined” rather than “refused”.  The family maintain Ms Yean was “talked out” of going to hospital; both interpretations are, in my view, strained.

I do not consider it unreasonable for a paramedic to advise a patient there may well be a significant delay in being seen at an Emergency Department, particularly if that paramedic has observed ambulances “ramped” earlier in the day.  The decision taken, while no doubt influenced by the prospect of a significant delay, ultimately was taken by Ms Yean, I do not accept she was refused transport to hospital.

The bottom line is, the offer of transportation was made, but declined.  Of course no one could have predicted the tragic event which unfolded sometime overnight, at a time I am unable to determine.

Professor Stephen Bernard, Senior Medical Advisor to Ambulance Victoria gave evidence.  He said (again, emphasis in original):

Bearing in mind that the paramedics are the professionals, I suggest that in the final analysis their assessment of the patient, following clinical guidelines, is the appropriate basis upon which a decision is taken to transport, or not.

That was not a position that the Coroner disagreed with.  As I said in that earlier post:

The coroner was not critical of the decision to advice Ms Yean of the likely delay nor of the decision of Ms Yean to choose not to go to hospital.  Paramedics are professionals and are there to exercise their professional judgment.  They could not have foreseen the consequence in this case.

My correspondent however changes the question.  What starts with advice that there is no indication that further treatment is indicated, subject of course to the paramedic’s limitations, becomes:

With registration for paramedics looming, I am particularly cautious of the cohort of patients who refuse treatment/transport against advice and the possible ramifications in the event that the patient does deteriorate

When I read the first part of the question the appearance was that the refusal was not ‘against advice’.  The confusion lies in identifying what is the paramedic’s advice.  If a paramedic forms a professional view that the patient would benefit from transport to hospital then they should give that advice, and if the patient refuses so be it.  If, on the other hand, the paramedic is of the view that transport is not warranted then that should also be the advice.  In that case the patient is not refusing transport against advice, they are declining transport based on that advice (as Ms Yean did).   One should not pretend that advice has been given to every patient and every patient who is not transported has ‘refused’ treatment. That was the perspective put forward by the paramedics who treated Ms Yean and was the perspective that coroner said was ‘strained’. Ms Yean heard the advice of the paramedics and chose not to (not refused) to go to hospital. Nor was she refused transport.

The critical first step then is to be sure what your advice is.  It might range from

  1. ‘There’s no need to go to hospital, transport to hospital would be a waste of everyone’s time” (in which case you would, hopefully decline to transport the person, a health professional should not provide futile treatment); to
  2. ‘There may be value in going to hospital, there are symptoms that I can’t be sure about the causes and transport to hospital may be beneficial, but you may have a long wait, I am unable to find anything life threatening at this time…’ and whatever else your advice may be; to
  3. ‘You are in urgent need of medical attention and I am concerned that if you do not agree to come with me your condition may deteriorate with long term consequences or you may die’.

A patient who chooses not to go to hospital after receiving advice suggested in point 2 above, like Ms Yean, is not refusing treatment against advice and there’s no point pretending that they are.  Pretending that your advice is to always go to hospital, when your opinion is that hospital treatment is not indicated is unhelpful, unconvincing and unprofessional (see also Refusing treatment documentation (June 9, 2016)).

Conclusion

I don’t really understand the question ‘Do you believe that a line exists between the component of informed – and the thought that we should be talking patients into being assessed at hospital?’    But I can say that I disagree with the ‘thought that we should be talking patients into being assessed at hospital’.  If that’s what paramedics are going to do let’s call them taxi drivers.

Paramedics need to give their professional advice subject to the limitations that paramedics face in making judgments about the patient’s condition.  But not everyone who rings for an ambulance needs to be transported to hospital. With registration as professionals paramedics will be expected to be professional and that means put their patient’s interest first. If that means advising them to go to hospital, then say that.  If that means discussing the costs and benefits and allowing them to make an informed choice then say that too.  And if that means refusing to transport then say that.

The patient who refuses treatment against advice is responsible for the consequences of their own decisions (see More on DNR tattoos (January 30, 2018)).  The patient who accepts your advice, or takes into consideration your advice and chooses not to go to hospital does not expose the paramedic to professional discipline.  I’ll leave the final word to Professor Bernard:

Bearing in mind that the paramedics are the professionals, I suggest that in the final analysis their assessment of the patient, following clinical guidelines, is the appropriate basis upon which a decision is taken to transport, or not.