Today’s question is about the standing of doctors vis-à-vis paramedics.  The question is:

… where do Paramedics stand if a doctor has stated to them (either in person or remotely (such as over the phone) that something needs to be done (such as a particular treatment pathway or transporting to hospital etc) and the paramedic(s) disagree? In essence, can doctors ‘order’ other healthcare professionals to do things as it relates to patient care?

For context I am a Paramedic in Victoria, and we have a ‘virtual emergency department’ (VED) that we can consult over the phone with a FaceTime like setup. Sometimes, though not often, Paramedics will consult VED, and the outcome of that consult is not a pathway that the paramedic thinks is appropriate or the ‘right’ thing to do. Another instance where paramedics might disagree with a doctor is when an ambulance is called to a GP clinic for a patient. The doctor might be certain that a patient requires transport to ED, but the paramedics might disagree upon their assessment.

I spoke to a local ED doctor about this, and he said that when he consults specialist consultants if he doesn’t get the advice he wants he will effectively ‘shop around’ and ask another consultant to get the desired advice he wants. Of course, he’s a doctor in an ED and I’m not, so I understand the context is quite a bit different there.

For reference within AV if I go against the advice of the clinician (a MICA Paramedic who is in the communication centre) I could be stood down and sent home for the remainder of my shift, not that I personally have done that, to be clear.

For a related post – see Step aside – I’m a doctor ( October 17, 2014)).

There are two issues here, one is the employment issue, and the other is the medical/professional issue.

Employment

If one works for an organisation, like Ambulance Victoria and they have a process in place where clinical questions can be escalated for advice and it is part of their direction to employees that they must follow that advice then that is, from the employment point of view, the end of the matter.  An employee must follow the reasonable directions of the employer and if those directions are to act on the advice of the clinician in the VED then that is what you have to do, subject to what I say below.

Doctors and paramedics

The clinical/medical perspective is more subtle.   It is (I hope) no longer the case that doctors are seen as the only people capable of making health care decisions with nurses and paramedics only there to carry out ‘doctor’s orders’.  Each profession has its own areas of responsibility and expertise.  All are health professionals.  The Code of Conduct for Paramedics says

Principle 5: Good relationships with colleagues and other practitioners strengthen the practitioner-patient relationship, collaboration and enhance patient care…

The code goes onto say (at [5.1])

Good practice includes that you:

1. communicate clearly, effectively, respectfully and promptly with colleagues and with other practitioners caring for the patient
2. acknowledge and respect the contribution of all practitioners involved in the care of the patient, and
3. behave professionally and courteously toward colleagues and other practitioners at all times, including when using social media.

The Medical Board of Australia’s Good medical practice: a code of conduct for doctors in Australia (October 2020) is quite different.  It says, uncontroversially (at [6.1]) ‘Good communication and clear understanding between healthcare professionals improves patient care’.  Perhaps controversially it reinforces the role of the GP as being responsible for coordinating care and (at [6.2.4]) ‘Ensuring that it is clear to the patient, the family and colleagues, who has ultimate responsibility for coordinating the care of the patient.’ Paragraph [6.3] says:

6.3 Delegation, referral and handover

Delegation involves you asking another healthcare professional to provide care on your behalf while you retain overall responsibility for the patient’s care.

Referral involves you sending a patient to obtain opinion or treatment from another doctor or healthcare professional. Referral usually involves the transfer (in part) of responsibility for the patient’s care, usually for a defined time and for a particular purpose, such as care that is outside your area of expertise.

Handover is the process of transferring all responsibility to another healthcare professional.

Good medical practice involves:

6.3.1 Ensuring there are arrangements in place for continuing care of patients when you are not available. These arrangements should be made in advance when possible, and communicated to the patient, other treating practitioners and any relevant facilities or hospitals.

6.3.2 Taking reasonable steps to ensure the person to whom you delegate, refer or handover has the qualifications, experience, knowledge and skills to provide the care required.

6.3.3 Understanding that when you delegate, although you will not be accountable for the decisions and actions of those to whom you delegate, you remain responsible for the overall management of the patient, and for your decision to delegate.

6.3.4 Always communicating sufficient information about the patient and the treatment they need to enable the continuing care of the patient.

Where a GP calls an ambulance for one of his or her patients, the process would be referral and handover rather than delegation.   The ambulance is providing a service to the patient, not the doctor (Zangari v St John Ambulance Service [2010] WASAT 6 discussed in detail in the post Step aside – I’m a doctor (October 17, 2014)). One can understand however that a doctor would be unlikely to welcome advice from a paramedic that the patient who they have assessed and with whom they may have an ongoing relationship does not need transfer to hospital.   They are referring their patient to the hospital and looking for the ambulance service to transfer the patient, they are not looking to the paramedics to tell them how to do their job nor are they looking to the paramedics for their advice on the patient’s needs. 

Professionalism would say, however that there were there is a clinical disagreement it should be resolved with professional communication and respect for each profession. The paramedics need to recognise that prior to their arrival there has no doubt been discussion between the doctor and patient about the diagnosis and why the doctor thinks the patient needs to go to hospital, the patient has one hopes consented to that course, if there is or will be ongoing care provided by the GP then this forms part of their care.    Doctors equally should recognise the standing of the paramedics and should be open to or wiling to answer questions about the need for transfer, but this must not devolve into an argument in front of the patient. 

Where there is a significant clinical disagreement that is likely to endanger the patient, the issue becomes more acute. There paramedics must be willing to back their own judgment and doctor’s orders cannot put aside their own obligation to assess and treat the patient.

If we return to the in-house system, the advice from the clinician might seem perverse or one might feel that they have just not fully understood the situation as described.  At the end of the day the paramedic on scene is the one who can observe the patient and the impact of the treatment.  If one really thought the advice was wrong and dangerous then one’s duty to the patient is paramount and should be put first.  That won’t mean that the paramedic may not face difficult times having to justify their actions but if they’re right and the outcome for the patient is good (or better than it would have been otherwise) one would hope they would be able to defend their position.  But you have to have the confidence that you’re right.  Usually much better to follow the advice and if there are real clinical questions about what the best course of action is, or was, to escalate them after the event through the employer’s processes for clinical review.

As for the doctor, doctors cannot direct paramedics what to do.  If the doctor wants the patient transferred to say a nursing home and en route the paramedics decide that an ED is more appropriate, then they need to make that call.  If a doctor prescribes medication to be delivered by the paramedics believe it is contra-indicated, then they cannot be compelled to deliver it.   It is hard to imagine however any circumstance where a paramedic would be justified in refusing to transport a person to ED where the doctor and patient wanted the transport.  There is no risk to the patient and if the transfer is inappropriate that can be escalated either through internal clinical review or the ED doctors can raise that with the GP.  To put it bluntly, it’s no skin off the paramedic’s nose to transport the patient when transporting patients is part of the job and that’s the job you’ve been tasked to do.

Discussion

Paramedics are health professionals with an obligation to put the patient first (Paramedicine Board, Code of Conduct, Principle 1).  There is an obligation to ‘practise safely, effectively and in partnership with patients and colleagues’ to obtain the best patient outcome.  An adage I like is ‘don’t ask advice if you’re not going to take it’ or alternatively, ‘if you don’t want the answer, don’t ask the question’.

If you are going to refer a matter to another clinician for advice, then you at least need to consider that advice if not follow it.

If you are transporting a person at the request of their doctor professional courtesy and respect means that of course you should bring to the doctor’s attention things you think they may have missed or misunderstood particularly if it poses an immediate risk to the patient but equally you need to respect their position and the relationship they have had with the patient which may be much more extensive than yours.

If you ask for advice and then don’t follow it, you may have to explain your position. You may have to explain it to your employer, the Paramedicine Board if someone alleges your decision to go against that advice was inappropriate professional conduct, or to a court if there is an adverse outcome and the issue is whether that would have been avoided if you had followed the advice.

But if you do follow the advice or direction that you think is wrong and likely to harm the patient then you may also be called upon to explain your position.  You may have to explain it to your employer, the Paramedicine Board if someone alleges that you should have identified the error in the advice/direction and at least brought it to the other practitioner’s attention or to a court if there is an adverse outcome and in particular if fears that you had at the time were realised. 

That you may have to explain your decision does not mean that your explanation may not be accepted and the fact that you followed your employer’s or doctor’s directions will be a significant factor in your favour.

Conclusion

Paramedics are not doctor’s delegates.  They are independent health professionals who have to make their own assessment in order to put the patient first. But they have to do that as part of a broader health system that includes medical practitioners who have different and more extensive training and may in the circumstances have a more significant and ongoing relationship with the patient.

Doctor’s orders do not set aside a paramedic’s obligations, but they are an important factor in deciding what is in the patient’s best interests and for ensuring continuity of care.  But if you think the doctor’s ordern or the clinician’s direction, poses an immediate risk to the patient’s life or health it is incumbent upon any health professional to raise that and to act in what they believe is the patient’s best interests.

This blog is made possible with generous financial support from (in alphabetical order) the Australasian College of Paramedicine, the Australian Paramedics Association (NSW), the Australian Paramedics Association (Qld), 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.

This blog is a general discussion of legal principles only.  It is not legal advice. Do not rely on the information here to make decisions regarding your legal position or to make decisions that affect your legal rights or responsibilities. For advice on your particular circumstances always consult an admitted legal practitioner in your state or territory.