Today’s correspondent is
… currently serving as an ambulance paramedic in Western Australia and have encountered a dilemma related to our professional duties when dealing with violent or aggressive individuals, or those experiencing severe mental health crises.
This issue arises from a recent policy shift by the WA Police, who now decline to accompany us to incidents involving individuals with a violent or aggressive history or current behaviour. Instead, we are tasked to conduct an “on-site risk assessment” and communicate the situation to the police, who will then decide whether their presence is necessary. Unfortunately, this has led to situations where paramedics have faced assault after police determined the reported risk did not warrant their attendance. Following such incidents, our ambulance service has implemented a new guideline stating that if the assessment by the paramedic team and a supervising paramedic deems the situation unsafe and the police decide not to respond, we are to withdraw from the scene.
This change prompts me to question whether our decision to not engage or to withdraw from a scene, based on our safety assessment, could impact our paramedic registration. Historically, we would wait for police assistance, but this new approach seems to conflict with our obligation to prioritize patient welfare, as mandated by AHPRA. Furthermore, we face a conundrum when encountering patients with mental health issues who are a danger to themselves or others but do not qualify for police intervention. Given that paramedics in WA do not have the authority to detain or transport these individuals involuntarily in the absence of police support, does this mean we must leave them unattended?
This situation appears to contradict our duties under AHPRA registration. These policy changes have led to significant concern and unease among me and my peers. Your thoughts on these matters would be immensely valuable.
It’s true that WA paramedics do not have the power to detain a person who is mentally ill, competent and refusing treatment, hat power is vested in WA Police – see Detaining the non-compliant in WA (July 21, 2019), see also Mental Health Act 2014 (WA) s 156.
The First Principle of the Shared Code of Conduct, that has been adopted by the Paramedicine Board, is
Put patients first – Safe, effective and collaborative practice
Principle 1 – Practitioners should practise safely, effectively and in partnership with patients and colleagues, using patient-centred approaches, and informed by the best available evidence to achieve the best possible patient outcomes.
As part of that principle the Code of Conduct tells us that good practice involves assessing ‘the patient, taking into account their history, views and an appropriate physical examination where relevant’ ([1.1](a)). Decisions about access to care require you to ‘treat patients with respect at all times’ ([1.3(a)) and:
keep yourself and others safe when caring for patients. While you should act to protect yourself, your colleagues and staff, if a patient poses a risk to health or safety, the patient should not be denied care if reasonable steps can be taken to keep yourself and others safe’ ([1.3](e)).
Good practice in an emergency requires that you ‘should offer assistance in an emergency that takes account of factors such as your own safety…’ ([1.4]).
Whilst you have to avoid or manage conflicts of interest ([8.10]) that is talking about business and personal conflicts not conflicts between patient care and your own safety.
It cannot be the case that the rule ‘Put patients first’ is at all costs to the paramedic. Paramedics do not have to take the homeless home, or spend their money buying meals or drugs for the poor, buy train or plane tickets for those away from home etc. Their professional duty is to prioritize ‘the best possible patient outcomes’ within reason and within the limits of their practice.
There is clearly no obligation on paramedics or other health care professionals to run unreasonable risks thought we accept and expect paramedics to do things that others would consider too risky eg working at accident sites, being winched into and out of helicopters, being exposed to trauma that carries a risk of long-term mental health issues. It cannot be said that paramedics don’t take risks to ‘put patients first’. Paramedics (and police, and firefighters) sign up to a high risk environment but what is an acceptable risk is a different matter. The sort of risks that are part and parcel of the job are to a greater or lesser extent managed by training, equipment and the ability to impose control on the environment.
Where a patient is mentally ill or aggressive it is an uncontrolled environment and, as noted, the agency with the authority to impose some control is WA Police, not St John Ambulance (WA).
The critical paragraph in the Code of Conduct is [1.3](e): ‘if a patient poses a risk to health or safety, the patient should not be denied care if reasonable steps can be taken to keep yourself and others safe’ What are ‘reasonable steps’ will depend on the circumstances. It may mean staying back for the patient and trying to talk them down. It may mean calling police or trying to connect with other health services, family or friends to see if they can persuade the person to accept care.
Police can intervene when the person has committed an offence (s 157) or (s 156) if:
… the officer reasonably suspects that the person —
(a) has a mental illness; and
(b) because of the mental illness, needs to be apprehended to —
(i) protect the health or safety of the person or the safety of another person; or
(ii) prevent the person causing, or continuing to cause, serious damage to property.
I therefore do not understand how a person ‘with mental health issues who [is] a danger to themselves or others … [does] not qualify for police intervention’. If the police don’t think the criteria in s 156 are met, and the patient is competent and refuses treatment and care, then yes there is nothing a paramedic can do. You don’t have to ensure everyone gets good care and you must leave them unattended in the same way you have to leave unattended a person who you think is having a cardiac issue, or who has a fractured limb, but who refuses treatment. Good care is predicated on consent and there is not only no obligation, there is no authority, to render treatment to a patient, no matter how much it is in their interest, if they refuse consent – and the presence of a mental illness does not automatically mean the patient cannot give or refuse consent.
If the patient is not competent then reasonable care can be given that is in their patient’s best interests but that still does not require you expose yourself to unreasonable risks to your own safety.
Conclusion
A ‘decision to not engage or to withdraw from a scene, based on our safety assessment’ could not impact paramedic registration provided it is done on the basis of a good faith assessment. Simply refusing to go to the scene without an assessment may be problematic as may a decision to simply leave without considering ‘if reasonable steps can be taken to keep yourself and others safe’ and provide some level of care even if that is not ideal care. If the patient is being belligerent simply walking away saying ‘&*%*( you I’m out of here’ is not good care. Stopping, even if a distance away, and thinking ‘is there something I can do? Is there someone else I can call?’ maybe the best care you can provide.
At some point if the patient appears to be competent and refuses treatment there is nothing you can do.
Your duty as a paramedic is to provide patient centred care. It is not a duty to solve all the patient’s problems nor is it a duty to do things you do not have lawful authority to do. And you cannot treat a competent patient without their consent.
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 
Michael, I note that your esponse is solely based on the OP’s question regarding AHPRA. Beyond that, you then have the separate considerations under relevant state Work Health and Safety legislation.
Where legislation creates an onus on both the employee and employer to ensure a safe workplace, and for the employee not to engage in unsafe acts, I would expect any AHPRA considerations would be mitigated by compliance with WH&S law.
Where the employee forms a view that a situation is unsafe and the risk cannot be mitigated, then the only reasonable response is to remove yourself from the threat. Unlike Police who are trained and entitled to use force and weapons, paramedics have no obligation to engage with violent potential patients in this way.
if you were to do so, and were injured, as unlikely as it is, you could potentially be prosecuted for WH&S breaches.
Further, it is up to the Ambulance Service to provide a safe workplace, which means either dealing with WA Police at a government level to change their policy, or by supporting paramedics to simply not engage in violent, or potentially violent situations.
I also note that AHPRA was never established with the thought of covering paramedics. The mindset and processes of AHPRA are far more aligned to health practitioners in the clinical setting; The safety of every worker should always take priority over other third parties.
perhaps this is an issue that needs greater attention by the union to force change.