Today’s correspondent, a paramedic from WA, wonders:
What, if any, are the legal considerations should a registered paramedic in WA wish to contact an agency who holds some level of guardianship for a patient (for instance Department of Communities or Disability Services) to raise concerns over the patient’s welfare and management.
For some context, imagine a patient who utilises emergency ambulance transport on a daily basis. The patient lives in a government run hostel or group home environment. The paramedic believes the staff may not be providing a optimal and responsible care for the residents, as a resident will leave the facility on a daily basis, and will request members of the public to call them an ambulance, to which of course they oblige. The responsible support staff at the Hostel seem disinterested when contacted, and resigned to the situation, and will request the hospital sends the uninjured and physically well patient be sent back by ambulance (at further cost).
Is there any way that a paramedic who is concerned by this unnecessary drain on a already over stretched emergency service and the overcrowded hospital, not to mention the cost ($900+ daily for the ambulance alone) to the taxpayer, is able to attempt to involve directly the responsibility department to advise them of the situation? Or would this be a breach of patient confidentiality, or business confidentiality (disclosing official secrets) etc, or both. Or should the paramedic resign themselves to being powerless to address these issues? Assume that hypothetically they were working for company with no process, formal or otherwise to attempt to address such issues.
To a certain extent, paramedics employed by a state-owned ambulance service or a contracted service such as St John (WA), are employed to do the job that their service provides to the public. If the service wants to provide services to people in these circumstances, recognising that there is more to ambulance work than just urgent ambulance work, then that’s their call.
It’s a different issue if the concern is actually patient welfare. A paramedic has a duty to take reasonable care of his or her patient. That may not always mean using advanced clinical skills but can involve a more wholistic approach.
Then there is the question of exactly what is the level of ‘guardianship’ that is held (to use my correspondent’s language). A person may be disabled either intellectually or physically but that does not mean they are not competent to make some decision nor does it mean that they do not still have rights including a right to privacy and that is a right not to have their clinician (in this case a paramedic) discuss their medical history with someone else. If the ‘someone else’ is an appointed guardian or if there is consent, or if in all the circumstances a person would expect the information to be shared then no problem. I note here that it’s ok for paramedics to share the clinical information they obtain with the triage nurse and treating hospital staff, that is why the information was collected and what everyone would expect them to do with it. Whether that would extend to say the manager of a person’s residential care facility is another matter.
Part of the solution is for paramedics to be supported by their agency to refuse to treat/transport people who do not need their services, but I do note again that one has to take a wholistic approach. It may not be what an intensive care paramedic sees as his or her job, but if the option is to leave a vulnerable person on the street without support, or to transport them home, then it may be quite an appropriate use of resources to transport them home recognising that an ambulance is not a taxi, but the whole person and all their circumstances do need to be considered. If the person is in a hospital it would seem that a taxi may be appropriate but there may be no-one to pay for a taxi but the person may be entitled to free (to them) ambulance transport. One can see the economic reason for using an ambulance when the alternative is that there is no-one to pay for alternative transport. If governments funded community transport that may be a different matter.
One can also understand why ‘The responsible support staff at the Hostel seem disinterested…’ they have limited resources and limited ability to control a person or direct their behaviour. The department may also take a similar view – there is not much we can do and if the doctor’s authorise ambulance transport home that comes out of someone else’s budget. How governments arrange their budget allocations is a matter for them so it may be that ambulance transport is the only transport available where someone is willing to pay for it, even if it is a ridiculous amount.
The way to deal with the matter, without breaching any duties, is to do research. Actually get de-identified data of how many people are using ambulances where that is not clinically indicated and what that costs and then put that before government.
In particular cases if there is a legitimate concern about the patient’s welfare and wellbeing (rather than concern about the use of ambulance resources) that can be dealt with as with any handover, by raising it with the treating staff either at the facility or the hospital. If the person is actually not competent to make decisions raising issues with guardians would also be legitimate.
If you work for a company that ‘with no process, formal or otherwise to attempt to address such issues’ then one might infer that they accept that providing this sort of work is part of what they do, and of course if they’re getting paid to do it, they may not think that’s a bad thing either in revenue terms and in terms of supporting the community’s vulnerable people.
One cannot really answer that question in the abstract. The answer will depend on each case, in particular: Is the patient mentally competent to make decisions? When it is said ‘an agency who holds some level of guardianship’ what does that mean? Is there an appointed guardian? What services are meant to be provided? By whom? On what terms?
In terms of the paramedic’s response are they concerned about the use of ambulance resources or the patient’s well being?
The answers to those questions will be different with respect to each incident and how those questions are answered would make a difference on what may be a legitimate response to the paramedic’s concern. It is not possible to make a general ‘yes’ or ‘no’ statement to the question ‘Is there any way that a paramedic … is able to attempt to involve directly the responsibility department to advise them of the situation?’