Today’s correspondent is a registered paramedic working in Queensland who asks
… a question about an issue which is commonly encountered by Ambulance services.
I can cite numerous cases where my clinical disposition has been that the patient should seek further treatment, however, does not require transport to hospital via emergency ambulance. Furthermore, provision of such transport would be an unnecessary use of healthcare resources, which would foreseeably prevent other members of the community accessing an emergency ambulance, for the duration of transport/time at hospital.
However, it is quite often the case where the patient states that they do not wish to drive, utilise family/friends, or pay for public transport/taxi in order to do this.
Most recently I attended a case where the patient did not wish to use available transport means and gave an ultimatum that she would not seek help at all if she wasn’t transported to hospital via ambulance. In this instance, a GP did refer her for further investigation at hospital, however the nature of her condition did not warrant an emergency ambulance for transport.
Sections 2.4 (d), and 5.2 of AHPRA’s Paramedicine Code of Conduct require wise & discriminate use of health care resources, and therefore not taking this into account would be breaching professional duty.
Having practiced in rural and isolated locations, it is also clear the inequalities for some Australians in terms of accessibility, due to distance/lack of services. While these people tend to have greater independence and personal responsibility out of necessity, I believe their use of an otherwise limited or ‘reserved’ resource can be validated. This also goes for other individuals without support networks which would leave them vulnerable. Therefore, the questions I ask are in the context where alternative pathways can be identified.
In summary, I ask:
- Does the fact that an ambulance is a means of transport, mean that providing transport is part of a paramedic’s ‘duty of care’ (for want of a better term)? I.e. A resource which may be used to access the greater health care system?
- Is it reasonable for a paramedic, in their findings, to request a patient utilise/burden their family & friends or pay for a taxi/public transport to access definitive health care?
- If the patient does not wish to utilise those means for financial or other reasons (e.g. cost of fuel/taxi, inconvenience etc.) does transport via ambulance constitute necessary use of healthcare resources?
Paramedics do not have to transport everyone and giving people advice about alternatives is reasonable – see:
- Transport everyone or act as a professional? A question for paramedics (May 6, 2013);
- No adverse comments regarding paramedics following death of a woman in Ballarat, Victoria (April 3, 2017).
What distinguishes the cases discussed above from the question is that in those posts, the issue was whether or not paramedics could refuse to transport, or advise against transport, where the patient was willing to accept that advice. The issue was whether a paramedic has to transport everyone who calls triple zero even if the paramedic does not think they need to go to hospital and where the person is willing to take that advice. That is not the case where it is agreed that further care is required, but transport by ambulance is not required. For posts that deal with the situation more like today’s question, see:
- Do paramedics have to transport everyone? (February 3, 2014);
- Paramedics decline to transport in NSW (March 21, 2014).
It seems to me that the critical issue here, and one that is still being resolved at a high policy level, is whether jurisdictional ambulance services are ‘emergency’ services or health services. Even if paramedics are experts in out of hospital emergency care that does not mean that ambulance services are only about emergencies. (And I suspect that the status of paramedics too is debatable, are they experts in ‘out of hospital emergency care’ or ‘out of hospital health care’?). Legislation establishing ambulance services is the responsibility of the Minister of Health (New South Wales and Tasmania), the Minister for Health and Wellbeing (South Australia) or the Minister for Ambulance Services (Queensland and Victoria). Only in the ACT is the relevant Minister the Minister for Police and Emergency Services. The Northern Territory and Western Australia do not have ambulance service legislation.
It is up to the operator of the ambulance service to determine what level of service they provide – that is what level of emergency and non-emergency transport they chose to provide. It is also up to the ambulance service to determine how they will staff their ambulances. It has been noted elsewhere that a paramedic has a duty to act in the best interests of their client. If an ambulance service says ‘today we’re paying you as if you had a lower skill set’ that does not and cannot define the level of care that the paramedic provides particularly in a life and death situation – see:
- Dual registered paramedics (November 27, 2018) and the comments that follow that post.
- All the posts that appear here: https://emergencylaw.wordpress.com/?s=volunteer+scope+of+practice.
But that doesn’t mean that it cannot work the other way, that is an ambulance service can employ a paramedic to provide emergency health care but also require that paramedic as part of his or her employment to provide less than urgent care.
From a simple financial point of view, given many ambulance services charge for attendance, even if they don’t transport then a person who is going to get charged for attendance may well decide it makes better sense to insist on ambulance transport as they’re going to get a bill anyway, rather than get an ambulance bill and pay for a taxi. That will certainly be the case if they have insurance to cover the ambulance costs. See
- Paying for ambulance services in the ACT (July 16, 2018);
- Paying for ambulance services(October 4, 2014); and
- Subtle change in the way ambulance fees are recovered in NSW(June 1, 2015).
Paramedics may think that is unreasonable but it is certainly a function of the fee for service model that applies both for ambulances and for taxis.
With that I can turn to today’s questions:
- Does the fact that an ambulance is a means of transport, mean that providing transport is part of a paramedic’s ‘duty of care’ (for want of a better term)? I.e. A resource which may be used to access the greater health care system?
Subject to the terms of employment and the nature of the service I would suggest that providing transport, including non-urgent transport, is part of a paramedic’s duty of care. People need to access the health service and the paramedic has to consider what the implications are for those they are called to treat. Some may not need ‘emergency pre-hospital care’ but they need or would benefit from hospital care. Consideration has to be given as to alternatives and whether they are available to the person – if they are poor, socially incapable or isolated, or for whatever reason cannot make alternative decisions then of course assisting them by providing transport may be the only reasonable choice. I do note my correspondent has noted this when they say their question does not apply to “…individuals without support networks which would leave them vulnerable. Therefore, the questions I ask are in the context where alternative pathways can be identified.”
- Is it reasonable for a paramedic, in their findings, to request a patient utilise/burden their family & friends or pay for a taxi/public transport to access definitive health care?
It may be reasonable to ‘request’ but harder to ‘insist’. A paramedic cannot know whether or not their patient has alternatives, that is whether they can afford a taxi or call on others for assistance. The paramedic may say ‘I’m not going to take you as your partner’s here and there’s a perfectly serviceable car outside’ but the paramedic does not know the nature of the relationship and how that partner may react once the paramedic leaves. If they say ‘there are no alternatives’ it must be hard to ‘go behind’ or challenge that claim.
Family and friends do not have an obligation to provide that service so again it would be hard for a paramedic to challenge a claim that a person ‘cannot’ call for others.
- If the patient does not wish to utilise those means for financial or other reasons (e.g. cost of fuel/taxi, inconvenience etc.) does transport via ambulance constitute necessary use of healthcare resources?
Ruth Townsend and I have previously written about what we see are problems with the ‘save triple zero for emergency’ programs – Michael Eburn and Ruth Townsend ‘Save 000 for emergencies: A flawed approach to reducing demand for emergency ambulance services’ (2017) 44(4) Response pp. 23-26. In essence those programs try to reduce demand by asking people who cannot know to decide whether their case is one that paramedics would regard as an emergency. What is required, we argue, is to manage supply. That does not mean have more ambulances, but to have alternatives to emergency ambulances. Ambulance services should consider (as Victoria Ambulance, discussed in that article, does) having alternatives, whether that is ambulances staffed by people other than paramedics or using alternative transport and/or health services. For my correspondent if there are alternatives provided by the ambulance service/health service then it stands to reason they should be utilised. If, on the other hand, out of hospital health services are provided only by QAS and only by qualified paramedics, then the fact that the case is not an emergency does not deny that it is a legitimate use of the states’ health resources of which QAS is one.
Conclusion
The issues being raised here are relevant at a much higher, policy level. It is up to the Ambulance Service and ultimately the state, to determine what level of service is to be provided and who they will employ to deliver that service. Certainly, paramedics should give advice to their patients and explore alternatives to ambulance transport. They do have a duty of care to their patients and that must include giving advice on whether they need further care. Paramedics cannot be obliged to provide care that they don’t think the patient needs – so refusing to transport someone who doesn’t need to go to hospital. But that is different to refusing to transport someone who does need to go to hospital but who does not need paramedic intervention en route.
In those circumstances, and subject to alternatives offered and policy direction from the employer, I would suggest it is consistent with a paramedics duty to his or her patient to transport the person if they indicate they do not have alternatives. You may suspect that claim, but it would be hard or impossible to prove that there are people they can ring or other transport they can take advantage of.
Australian Emergency Law 
Making your own judgment can place you at risk of an ‘inquiry’, should something adverse occur to the subject person.
There have been Mental Health situations, where the subject was considered ‘non urgent’ …. and later suicided unsupervised.
Even when waiting at the ED, adverse events can occur.
‘Damned if you do ….. damned if you don’t’ !!
I don’t really understand this type of comment. As a community we spend large amounts of money trying to preserve life and to understand how and why unexpected deaths occur. An ‘inquiry’ means someone is asking a query – a question. You are ‘at risk of an inquiry’ but of course you may be asked, as may anyone, to explain what happened and your line of thinking. But just because you are asked a question does not mean there is not a good answer and it does not mean that the inquirer is looking to ‘get’ you – see https://emergencylaw.wordpress.com/2018/12/01/first-aid-and-paramedic-care-and-coroners-are-not-out-to-get-you/. Adverse events can and do occur and if you work in the paramedic sector, they are going to happen to you. But that does not equate to being ‘damned’ no matter what you do. Paramedics have to make decisions and people die, sometimes trying to understand the link is important.
Interesting topic and one I’m sure we have all thought about.
Would it be plausible and as I work in NSW there would be a possibility to use alternative non emergency transport.
If the pt does not wish or have access to alternative transport options from family/friend’s or public/private and after assessment by the responding paramedics it is deemed to be appropriate for the use of other services should it then be appropriate for the Paramedic to be able to request the use of patient transport services to take the pt to hospital?.
It seems to me that may be a reasonable response, that sounds like non-emergency patient transport – but whether that’s the way the services operate I can’t say. If we go back to when I was in ambulance (in the late 1980s) we ambulance officers did the non-emergency work and emergency first response. If was a real emergency we called for intensive care paramedics (and they were the only ones called paramedics). Now everyone’s a paramedic and the demand for emergency services has gone up, but there is I suggest space for non-paramedics to provide ambulance transport. If and how an ambulance service choses to do that is a matter for them but it would seem like a sensible space for NEPT providers. Something to take up with your service perhaps?
“Inquiry” meant Coroners Court; employer disciplinary process; police investigation, or simply media attention.
And Michael, if you think that there is nobody ‘out to get you’ for the slightest mistake or error of judgement ….. then you have had a charmed life. The rest of us in any field of ‘Health’ ARE at constant risk of all manner of “inquiry”.
In the case of a State Ambulance Service, the media will ‘hound you to death’ if a child dies as a result of something ‘adverse’ ( which could be anything from delay in arrival at scene; to wounds inconsistent with life ).
In my experience as an RN for 26 years, I am aware of the ‘dangers’ within our State Health systems …… ambulace, hospital, community care, and even within families …… things go wrong, and people die or kill their family and friends.
( not quite relevant to this thread …. but did you know, that under the ‘care’ of DVA, their has been around 90 suicides of ex Defence personnel in the last 18 months ? Fed.Govt. covers those stats up, and so do State Govts. with what happens within our Health systems. It looks ok, but it isn’t really ).