Today’s correspondent is ‘… a fairly junior paramedic working for the Queensland ambulance service (QAS)’ who hopes I can provide:
… some clarity surrounding medication safety law/guidelines.
Specifically, my question relates to registered paramedics providing medications (S4s/S8s) to patients and the patient’s right to refuse transport / further clinical monitoring – or a paramedics responsibility with providing this form of treatment with the knowledge that this patient will likely refuse transport after treatment is provided.
This question comes from the general consensus among many clinicians and both university educators being that we (paramedics) should not provide medications or refuse to administer medications if the patient is likely going to decline transport to hospital. In general this refers more specifically to comfort care such as antiemetic or analgesia type medication management, opposed to life saving medication such as adrenaline.
My immediate thought was ‘what’s the issue?’ If my doctor prescribes schedule 4 drugs I go to a chemist, get the script filled and go home and take the drugs – no-one’s supervising me so the issue cannot arise just because the drugs are schedule 4. And whilst I’ve not been prescribed s 8 drugs, I can imagine that in many cases they are taken by people without supervision. I asked my correspondent to give further details and they replied:
I was thinking more along the lines of the liability associated with Ondansetron as an S4, and administering it on a non-transport job and if there are different legal considerations for IM vs Oral routes.
But am also curious of your opinion for S8s in the same manner say for IM Morphine or IHL methoxyflurane – where these have been administered as analgesia but then the patient decides they want to decline transport after since they’re pain is now controlled.
(The links above are to the relevant Queensland Ambulance Drug Therapy Protocols. I note methoxyflurane is S4, not S8; see Therapeutic Goods (Poisons Standard—October 2023) Instrument 2023 (Cth)).
I infer the question relates to ‘comfort care such as antiemetic or analgesia type medication management, opposed to life saving medications such as adrenaline’ because a person who needs adrenaline for the treatment of the conditions listed in the QAS Drug Therapy Protocols: Adrenaline (Epinephrine) (DTP_ADR_0323, March 2023); that is:
- Cardiac arrest
- Anaphylaxis or severe allergic reaction
- Severe life-threatening bronchospasm or silent chest
- Shock unresponsive to adequate fluid resuscitation
- Bradycardia with poor perfusion [or]
- Croup
is unlikely to be able to or refuse treatment, but is that necessarily so? A person with a severe allergic reaction may, I assume, respond rapidly to the treatment, and then decline further treatment and transport. If that’s correct, I’m not sure why the distinction between ‘comfort care’ and ‘life saving medication’ is relevant.
In any event let’s now turn to the issues raised.
First, if a patient is given a drug and then refuses further treatment or transport there is nothing the paramedics can do about that. A person can refuse treatment at any time. They are not compelled to comply with paramedic directions because they complied a moment ago. Consent is a process not a single step and can be withdrawn at any time.
Second, if the patient ‘will likely refuse transport after treatment is provided’ I fail to see how that would be grounds for withholding the treatment they consent to. One of the principles of bioethics is ‘justice’ which in simple terms is about giving people what they need on the basis of need rather than other, irrelevant considerations. In this case none of the Drug Therapy Protocols suggest for example that the drugs should only be given when patients can be monitored or that the administration of the drugs necessitates some hospital only follow up. If you give a person an anti-emetic or analgesia so they can then follow up with out of hospital care, or perhaps attend to a pressing need (like making arrangements for their children) and then make their own way to hospital, haven’t you provided a valuable service to the patient, the health system and the community?
Given that methoxyflurane lasts for 5-10 minutes there may be a fear that the person thinks the pain is relived but if you go they’ll call you back when the drug wears off. That is no reason not to give the drug and it is no warrant to force the person to accept transport. You tell the patient, and ‘go slow’ on the pack up until they realise that no, whatever was hurting before, still hurts.
Finally there is the circumstance where the patient has made it clear that they are not going to accept transport but are willing to accept care on the scene. That may be an issue with a drug like morphine in that it can cause bradycardia, respiratory depression, nausea and vomiting, hypotension and drowsiness. They may all be problems if the patient is left alone.
There could certainly be an argument that you could say to a patient ‘if you’re not going to come with me I cannot give you this drug, because of its dangerous potential side effects’. I cannot see how that arises with the other drugs listed (at least from what I can infer from the drug protocols) and it doesn’t change the fact that even if they agree, once you have given the drug, they can then refuse further transport and there is nothing you can do to force them if they remain competent to make the decision.
Conclusion
There is no legal reasons to conclude that paramedics ‘should not provide medications or refuse to administer medications if the patient is likely going to decline transport to hospital’. As paramedics you are there to deliver health care, the days of just being a transport service are over. You deliver care to the patient based on the patient’s needs often with the hope that the care you deliver will mean they don’t need further transport to hospital.
There may be an argument with respect to some drugs that you should not administer them if you think the patient needs to be monitored afterwards given the drugs possible side effect but even with morphine that could be met by telling their family or friends – ‘they don’t want to come with me, but look out for these symptoms and call us back if any of these things happen’.
The law asks you to act reasonably in all the circumstances which includes making clinical judgements such as whether the risks to the patient outweigh the benefits where the patient has made it clear that they are going to refuse further transport. There is however no law that says ‘no transport, no drugs’ and it would appear to me (recognising that I am not a clinician) that for most drugs that is not an issue. A blanket rule of ‘no transport, no drugs’ would be the antithesis of good health care.
This blog is made possible with generous financial support from the Australasian College of Paramedicine, the Australian Paramedics Association (NSW), Natural Hazards Research Australia, NSW Rural Fire Service Association and the NSW SES Volunteers Association. I am responsible for the content in this post including any errors or omissions. Any opinions expressed are mine, and do not necessarily reflect the opinion or understanding of the donors.
Australian Emergency Law 
I received this comment from a Senior CCP via email:
I read this post with interest and indeed surprise that this thinking still persists, and indeed that “university academics” may (or may) be persisting in it.
I would suggest it is not uncommon to not transport someone after administration of some medications, indeed the CPM actually encourages it (or does not discourage it) in an appropriate setting.
Conditions that have had medications administered more than paracetamol/ibuprofen (while not exhaustive) could include:
Unconscious T1 diabetes requiring IV glucose
Fish hook removal requiring local anaesthetic
Heat stress requiring IV fluids
Nausea secondary to alcohol use needing fluids +/- antiemetics
Arguably even the uncomplicated healthy birth
The list would easily go on and of course this has to be undertaken with a comprehensive risk assessment of the patient’s condition, medical history, etc, etc.
I think you hit the point correctly – indeed transport is ultimately the patient’s decision (provided they have capacity), however where this junior clinician may be getting confused is the nuance of what treatment to provide balanced against the likelihood of refusal, balanced against the risk profile of that medication and/or procedure.
More “serious” medications, such as Ketamine, Morphine or Midazolam require a higher level of post administration monitoring – and therefore the patient would be unsuitable to remain at home.
For a condition that upon assessment may be able to be resolved on-scene, and likely would not require transport (for example I had a child whom had their leg stuck in the wheel of a pushbike – painful and required manipulation to remove it – so opted for inhaled methoxyflurane – as once it was removed….voilà child is pain free and running around! However, had I used Fentanyl (inhaled) I would have insisted on transport (upon which the parent would have been within their rights to refuse).
But even this has nuance. Perhaps this is an end stage palliative patient, although in this setting for a variety of other reasons, we seek physician advice before narcotic administration.