Today’s correspondent says:
A State Ambulance Service has recently released a policy on surge response. At it highest level, this surge policy dictates that paramedics do not complete paperwork for patients and that only critical care be administered on scene. Rather paramedics should expedite transport and drop patients at the nearest hospital without documentation (our major centres only have one hospital each).
As individually registered paramedics, do we have an obligation to treat the patient in front of us with the most appropriate care and then document that treatment? Is this directive legal and what are the potential ramifications to individual paramedics if we follow or don’t follow this policy?
To be clear, this surge policy will likely be implemented on a semi-regular basis and not reserved for mass casualty scenarios.
That’s a very complex and difficult question. To think about an answer, I’ll start with the Health Practitioner Regulation National Law. The primary professional duty on a paramedic is to practice paramedicine in a way that ‘might reasonably be expected of the health practitioner by the public or the practitioner’s professional peers’ (definition of ‘unprofessional conduct’). Principally that will involve providing the best, most technically proficient care to the patient before them, taking into account the patient’s condition, wishes and values.
Where a person rings for an ambulance and is advised that an ambulance is or will be dispatched, then the ambulance service may owe a duty of care to that patient (Kent v Griffiths  QB 36). In that case the ambulance service has entered into some sort of relationship with the patient. But the same cannot be said of individual paramedics, a paramedic employed by [Jurisdictional] Ambulance Service cannot owe a duty of care to every patient that has called the ambulance. A paramedic treating a patient in Drummoyne does not owe a duty of care to a patient in Coonamble even if NSW Ambulance does (noting here that this question does not come from NSW, it’s just an example using two stations I used to work at). My starting point is, then, that the paramedic treating a person owes his or her principal duty to the patient currently in their care, not to the other patients that may be waiting.
But it’s not that simple. Indeed, the jurisdictional ambulance service has a duty to manage resources to meet demand and it does need to try and service the entire community. It does that by employing paramedics and, as employees, paramedics have a duty to obey the lawful and reasonable directions of their employer.
There are also ethical principles at play here. In a leading text on medical ethics, Beauchamp and Childress, Principles of Biomedical Ethics, (now in it’s 7th ed, 2012) identified four principles. They are:
- Non-maleficence; and
Personally I prefer to say ‘respect for autonomy’ and in simple terms beneficence may be ‘do good’ whilst non-maleficence is ‘do no harm’. They are relevant here. With respect to the principles of beneficence and non-maleficence the ethical duty on the paramedic is to do the best that she or he can for the patient and not to withhold treatment where that might harm the patient.
But there is also the principle of justice which again in a rough translation equates to ensuring people get the care they need on the basis of their needs and need alone. Medical practitioners face the demands of justice because even though they are treating ‘their’ patient they cannot advocate to push their patient up the list to get access to surgery, or a test, nor can they divert resources to their patient that another patient needs more. They have to consider the greater public good when determining what resources should be allocated to their patient. For paramedics this will not usually be an issue. A paramedic treating their patient is not usually diverting resources that may be used elsewhere or for another. But where there is unmet demand that may be the case. Providing care to a current patient may be nice but to the extent that it means another person foregoes care it does raise the issue of justice and who is more in need of the service the paramedic can provide.
I’ve previously talked about not completing paperwork- see
- Delaying the case sheet to respond to an urgent call – NSW Ambulance (January 21, 2017); and
- Completing paramedic case records (September 3, 2015).
As for ‘only critical care be administered’ whether that’s reasonable will depend on all the circumstances. There is a difference between care that is critical, without it the patient will die or be left with significantly more serious injuries; and care that is nice – good in an ideal world with lots of time whether that provides better continuity of care (so perhaps that second set of obs) or provides the patient with more comfort (staying with them in casualty until a bed becomes available; see Paramedics leaving patients in casualty (January 24, 2015) but are not really necessary.
The critical questions will become whether in all the circumstances it was reasonable for the relevant ambulance service to ‘activate’ the policy and whether it was reasonable in all the circumstances for the paramedic to do what he or she did in response. If a paramedic can comply with the policy without it causing serious harm to the patient and if there really is a significant surge in calls on ambulance resources, then it would seem appropriate to respond accordingly. If compliance would pose a real and serious risk to the life or health of the patient, then a paramedic may have to say ‘I’m not complying’. Having said that I do note my correspondent says that the policy does expect that ‘critical care be administered’ so, presumably, it is accepted that paramedics will not withhold care that is necessary to preserve life or prevent serious injury.
Without seeing the exact terms of the policy, one cannot comment on the details, but the principle has to be unobjectionable. At the end of the day what is critical care for the particular patient will fall to the professional judgment of the treating paramedics. That will require consideration not only of the patient’s needs, but also the directive from the employer and some assessment as to what calls are waiting to be responded to. At the end of the day the paramedics obligation is to act, taking into account all the circumstances, in a way that ‘might reasonably be expected of the health practitioner by the public or the practitioner’s professional peers’.
Without seeing the policy this answer is bordering on mere speculation. Even so I would infer, from what I’ve been told, that the policy is saying, in effect, ‘we expect you to do this, unless there is good reason not to’.
Failure to comply may be a failure to obey a reasonable direction and in extreme circumstances could be grounds for dismissal.
But if the policy says ‘only critical care be administered on scene’ it is up to the paramedics to determine what is critical for this patient. Providing critical care at the scene is applying the policy (at least as it’s described to me). Another way to understand the policy may be as ‘we give you permission not to do everything you would otherwise do’ again leaving it to the paramedics clinical judgment to determine what, if any treatment, is not ‘critical’ today.
In terms of civil liability (if any) it will fall to the ambulance service. In terms of professional liability (if any) the question is did the paramedic act in a way that ‘might reasonably be expected’ in all the circumstances including the implementation of the surge policy, not did he or she apply every step in every CPG and tick every box. Paramedics are not automatons, they are professionals so it will be did they exercise their professional judgement.
Having written the above I have now been sent the relevant policy. I note that it says that the action ‘Assess the need for limiting non-essential on scene care in preference of expedient transport’ only arises at surge level 5 – Disaster Response. My correspondent’s claim that ‘this surge policy will likely be implemented on a semi-regular basis and not reserved for mass casualty scenarios’ seems unlikely. There are thresholds for surge levels 1 through 4 and it would be hard to pretend that something was a disaster response when it was not. I would suggest the way the policy was first reported is not a fair reading of the document, but even so the discussion above still identifies relevant considerations.