This question from a paramedic in Queensland was originally posted in response to my post on “The need for a medical director in an ambulance service” but I thought it warranted it’s own post and comments. The question is:
I would like to know if the use of disclaimers used on ARF’s (ambulance report forms) has any legal strength. For example, I have been directed to transport every Patient I attend no matter what the the case involves. If the Patient or their carer does not want to be transported I am then to complete a VIRCA (voluntary refusal without coaxing from family friends etc, informed of their condition and potential for harm no matter how unlikely, reverent to this patient and their condition, the capacity to refuse not effected by drugs of consenting age etc, advise for further treatment such as attend a GP). The use of the VIRCA is now so common in Queensland that paramedics either transport every patient to hospital or deem them to have refused transport and included this disclaimer in the paper work.
I can understand doing this if the Paramedic believes the Patient is at risk, but to do this for every Patient who has the right to stay at home just so the Ambulance service can avoid legal action if the Patient complains at a later date seems over doing it. I all ways thought if a Paramedic was asked to defend their actions some months or even years after the event, they could refer to their report form and then prepare a statement. I am being told that if a case went to court my ambulance report form will be my statement and if I have not documented a VIRCA then I will have breached my duty of care. To me the addition of a disclaimer on every job not requiring transport and the push to transport every patient to hospital is difficult as I am a rural paramedic. I also feel that I am scaring people and transporting case that could be left at home.
In answering this question I’m going to refer to ‘you’ as meaning all ambulance paramedics who have to make decisions, not my correspondent alone.
If a paramedic owes a patient a duty of care, the duty is to act professional, with clinical skill and in the patient’s best interest. The duty is not to complete paperwork. Accordingly advice that “if I have not documented a VIRCA then I will have breached my duty of care” is clearly wrong. What that advice means, if it has come from ambulance management, is “if I have not documented a VIRCA then I will have breached my duty of care” to the ambulance service as you have not given them a record that they can rely on to confuse the situation in some bizarre hope that it will give them a defence to any claim. You do not have a duty to play that game.
Now to the point. If paramedics want to be treated as professionals they have to be willing to act in their patient’s best interests using their clinical skills and experience to help the patient form a judgment as to what that may be. Let us assume that you are called to an elderly person who, after a large family lunch, stood up and felt a bit dizzy. Before she had time to recover a concerned family member has rung triple zero and you are on your way. By the time you get there she’s feeling fine and you do an examination. Let us assume that the patient is conscious, lucid and cooperative. She allows you to take a blood pressure, measure her pulse, blood sugar levels, conduct an ECG and do whatever else it is you need to do and assess her condition. Everything’s fine. Your professional conclusion is that she was sitting down in a warm room, eating a large lunch, she stood up had a mild drop in blood pressure but it’s all good now (remember here that I’m not a clinician so let’s assume that all I’ve said is true and not quibble if I’ve got the science wrong). Let us also assume the patient is in fact compliant and would go with you to hospital if you tell her she should.
If you’re going to act in the patient’s best interests and your professional opinion really is there is nothing wrong then it would not be in the patient’s best interests to transport them to hospital. If you are being asked “to transport every Patient I attend no matter what the case involves” you are neither being asked, or allowed to act as a professional. If you have a duty to the patient it’s in fact a duty not to transport them and that would also be the duty (an ethical not a legal duty) owed to the community, not to tie up the ambulance and the hospital for no good reason.
If you complete the VIRCA (and I’m not sure that that acronym stands for but you’ve said “voluntary refusal without coaxing from family friends etc, informed of their condition and potential for harm no matter how unlikely, reverent to this patient and their condition, the capacity to refuse not effected by drugs of consenting age etc, advise for further treatment such as attend a GP” so I’m assuming you write to that effect on the case sheet) then you’re simply lying and that is not going to help.
Let us assume that ½ hour after you leave, the patient collapses with a heart attack and the family allege negligence for not transporting the patient, but the ambulance service claims that the heart attack was just pure coincidence. At the time you attended there was nothing wrong with the patient warranting treatment or transport but ½ an hour later there was.
That case would turn on the medical evidence about the patient’s condition and whether it was or was not present or detectable when you were there. If you’ve written on your case sheet that you did all sorts of things that you did not do, then the family are going to see that and say to their lawyer ‘that’s not what happened’ and you cannot ‘deem’ the patient to have refused transport, either they have, or they have not refused treatment. Suddenly a case that might have settled is not going to settle because the family and their lawyer is are going to point to the case sheet and say ‘that’s not what happened, the paramedic’s a liar, what have they got to hide?’ and suddenly the case is longer, more complex and unnecessary.
On the other hand, if you’ve recorded your actual clinical findings and your opinion then, as you say if you’re “asked to defend [your] actions some months or even years after the event, [you can] refer to their report form and then prepare a statement” about how and why you formed the opinion you did. And that would support the conclusion that the condition that manifested ½ hour later was not present or detectable at the time.
The reason medical records (or any business record) is accepted as likely to tell the truth, is because it is assumed it is being written to record the truth. Accordingly your case sheet that records your observations and treatment is probably accurate because why wouldn’t it be. If however you start completing forms to say you did or believed various things that you did not believe (such as warning the patient they may face serious adverse consequences if they don’t go to hospital when in fact you don’t believe that at all) will throw into doubt everything you have written.
In short doing something simply so ‘the Ambulance service can avoid legal action if the Patient complains at a later date seems over doing it’ is unlikely to actually achieve that objective, it will just possibly change the nature of the legal action, is unprofessional and unethical. That’s not a criticism of the frontline paramedic but the wrong advice and misunderstanding of what the law requires that is the basis of the advice you are being given.
What follows is if you have received advice that “if I have not documented a VIRCA then I will have breached my duty of care” that advice is wrong.
The mere fact that someone has rung for an ambulance does not mean an ambulance is required, nor does it mean the person who rang should have known that. They are asking for a professional health service and sometimes that service can include advice that treatment is not required, or some other treatment, other than transport to hospital is appropriate. If you have been told ‘you need to transport everyone regardless of your professional opinion’ then I would want to see where that is recorded in your treatment protocols or clinical practice guidelines. Again if it is a mangers interpretation of what the law requires it is again wrong, unethical and unnecessary. Such a policy denies that a paramedic is health care professional, rather it assumes you are an ambulance driver or stretcher bearer and that you cannot be trusted to act in your patient’s best interests.