A correspondent says:

When patients refuse treatment paramedics are now being in encouraged to use the VIRCA assessment. This is to ensure the decision is voluntary, informed, relevant, made with capacity and the patient is left with adequate advice.

There are some occasions when crews will be directed to transport a patient to a hospital which is significantly further away from the patient’s home than the nearest available hospital. This decision is usually made based on patient flow statistics. There is a cohort of patients who this presents an issue for, as it takes them away from their support network and locality.

VIRCA suggests that the decision to refuse treatment should be relevant and relate to the treatment being recommended. This suggests that a refusal to be conveyed to hospital based solely upon the destination alone does not meet this criteria.

As a registered paramedic the professional standards code of conduct states:

2.1 (a) assessing the patient or client, taking into account their history, views and an appropriate physical examination where relevant; the history includes relevant psychological, social and cultural aspect

2.1 (e) recognising and respecting the rights of patients or clients to make their own decisions

2.2 (d) practicing patient/client-centered care, including encouraging patients or clients to take interest in, and responsibility for the management of their health and supporting them in this

2.2 (f) considering the balance of benefit and harm in all clinical management decisions

It will often be an instruction that if the patient refuses to be taken to the designated hospital they should be left at home with the appropriate paperwork completed. If the paramedic makes a decision to ignore this directive because the VIRCA assessment cannot be met and the patient cannot be safeguarded, one would assume that could lead to potential disciplinary action from the employer? Conversely, if the patients is left at home, as per the employer’s instruction, after a refusal based solely on location of hospital and later came to harm, it appears the code of conduct may have been breached and this could impact on the paramedic’s registration? In this situation the employer is making decisions based on operational constraints however, as a registered clinician decisions need to be clinical and patient focused. It appears a paramedic in this situation can be left in a vulnerable position regardless of how they proceed? Your thoughts around this would be interesting to hear.

The High Court in Rogers v Whitaker said ‘except in cases of emergency or necessity, all medical treatment is preceded by the patient’s choice to undergo it’.  What factors a person takes into account in deciding whether to accept treatment, including location, is a matter for them and for their values.   Advice can be rejected ‘for reasons which are rational, or irrational, or for no reason’ (PBU & NJE v Mental Health Tribunal [2018] VSC 564, [145]). The idea that ‘the decision to refuse treatment should be relevant and relate to the treatment being recommended’ is quite wrong.  It is not for the ambulance service to say what factors a person has to consider relevant.  If the option is go to hospital B (instead of hospital A) or don’t go at all, it is the patient’s decision based on whatever factors the patient wishes to take into account.  A ‘refusal to be conveyed to hospital based solely upon the destination alone’ is entirely valid and a matter for the patient.

The right of a patient to make decisions for their own health care is not a right to insist that those decisions are honoured.   I can insist that a doctor prescribe antibiotics for my viral infection but the doctor is under no obligation to meet that demand.  I could demand that I receive a particular treatment at my local hospital but if that hospital doesn’t provide that treatment I cannot complain that they are not ‘recognising and respecting’ my right to my ’own decisions’.  Equally if a hospital is overloaded or closed the patient cannot insist that they be taken there, an ambulance is not a taxi.  They can accept, or reject, the treatment and care that is being offered.  Within limits a paramedic or ambulance service should consider views and social history and consider whether the patient’s preferences can be accommodated but it does not mean they must be.

If a paramedic were to ignore an employer’s directive to take a patient to hospital B and instead go to hospital A one would hope that was based on clinical grounds – that is the patient’s condition including their social position meant that the benefit in going to hospital A including waiting time for the patient and the paramedic exceeded the potential harms.  I cannot speak for any ambulance employer but it’s hard to imagine that there could be disciplinary action if that was an informed and documented clinical decision (though one may be asked to explain that decision).

Making decisions on operational constraints has to happen all the time.  The decision of what clinical level paramedic to send to a job, how jobs are prioritised etc are all decisions based on ‘operational constraints’.  If the nearest hospital cannot receive patients then there is not point transporting a patient there.

Assuming that a direction ‘to transport a patient to a hospital which is significantly further away from the patient’s home than the nearest available hospital’ is made on clinical grounds – eg that the nearest hospital has advised it cannot take patients or only those with life threatening emergencies – then that is a legitimate position.  If a patient is advised that they can only be transported to hospital B they are entitled to refuse transport on that ground alone.  Taking into account the patient’s social standing and the value of being supported at a local hospital may require the paramedic to consider contacting a supervisor to discuss the paramedic’s concerns and why transport to A is clinically indicated and also, perhaps, contacting hospital A to see if they can accept this patient and why that request is being made.

If it is simply not possible to go to hospital A then that is the reality.  And just as a patient cannot insist that they be taken past the nearest hospital and instead be taken to one closer to home, nor can they insist to be taken to the closer overworked hospital.  If the patient’s wishes can be accommodated then they should be, but if they can’t be then they can’t be.

I cannot see that the paramedic is in a vulnerable position if he or she listens to the patient’s concerns and considers them.  If at the end of the day the patient does not want to go that is his or her right.