This question from a MICA [Mobile Intensive Care Ambulance] paramedic in Victoria who writes:

… in the course of doing monthly clinical audits I came upon the following scenario and was hoping to get an opinion from you as to appropriate actions and / or responsibilities.

Two ALS paramedics were called to a nursing home in answer to a request to transport an elderly demented patient who had become difficult to physically manage by the nursing home staff, including frequent outbursts of violence – unfortunately not uncommon in dementia but usually medicated for, but not on this occasion.   In Victoria we have a guideline that allows for sedation of the “agitated or aggressive” patient, via intramuscular or intravenous Midazolam.   On this occasion the nursing home staff instructed the ALS paramedics not to administer any treatment including sedation.   A discussion ensued during which the relative with Medical Power of Attorney was contacted, who also refused any treatment but demanded transport to hospital.

My question is this:  in the above scenario what are the obligations, responsibilities and “rights” of the attending paramedics?

Consent to medical treatment is a fundamental issue in bioethics and health law. One cannot give treatment without the patient’s consent or other lawful authority, but that does not mean that you have to give everything the patient consents to. For example a person may go to the doctor seeking antibiotics for their viral infection, they may consent but that does not mean the doctor has to give the prescription.   In a more dramatic scenario, the patient may wish to impose conditions but that may mean the treatment can’t be done, for example a person may consent to surgery but for some reason say that they do not want the doctor or nurses to wear gloves. In those circumstances it may be said that the treatment cannot proceed. The right, indeed the need for consent, does not mean that one has to do everything the patient wants but of course it is prudent and right to consider what the patient wants and accommodate their wants if that can be done. There are lots of reasons why the patient’s wishes cannot be met, they may mean the treatment will be ineffective, that it will be too dangerous, or that it poses an unacceptable risk to the health staff or others.   Let us then consider the scenario we’ve been given.

First, just because ‘the nursing home staff instructed the ALS paramedics not to administer any treatment including sedation’ it does not mean that the paramedics have to follow that direction. Imagine if the boot was on the other foot and a paramedic arrived at hospital and told the doctors and nurses not to administer some particular treatment. I’m sure they would rightly thank the paramedic for his or her advice and then ignore the direction. Paramedics are no more a nurses handmaiden than nurses, today, are the doctor’s handmaiden. Paramedicine is it’s own discipline, with its own professional standards. Providing ‘ambulance’ care is not the same as providing nursing care (though there may be many overlaps). One critical issue for ambulance paramedics is not only the patient’s interest but also the safety of paramedics in the confined space of the ambulance and the risk to other road users.   If the patient is ‘difficult to physically manage … including frequent outbursts of violence’ then they pose a risk to road users should they become violent on the road, and that needs to be managed.

Ambulance Victoria Clinical Practice Guideline CPG A0708 deals with ‘The Agitated Patient’. That guideline ‘does not apply to Pts [Patients] who have been recommended for Tx [treatment] under the Mental Health Act’ and I will assume, therefore, that this patient was not being treated under that Act. As that CPG states ‘Paramedic safety is paramount’.   If underlying causes have been managed appropriately but the patient remains agitated Midazolam may be administered.

In this case a ‘discussion ensued [with] the relative with Medical Power of Attorney … who also refused any treatment but demanded transport to hospital’. An agent who has been given an ‘Enduring Power of Attorney (Medical Treatment)’ may make decisions regarding a person’s health care (Medical Treatment Act 1988 (Vic) s 5A).   The agent may refuse treatment if, and only if, they have been informed of the patient’s condition and understand that information; and

(a)      the medical treatment would cause unreasonable distress to the patient; or

(b)      there are reasonable grounds for believing that the patient, if competent, and after giving serious consideration to his or her health and well-being, would consider that the medical treatment is unwarranted. (Medical Treatment Act 1988 (Vic) s 5B).

The problem with the story that we’ve been given is that we don’t know why it was thought sedation was not appropriate.

It is not clear, if a conversation occurred whilst the ambulance was there wanting to transport the patient, if the medical attorney could have been sufficiently informed to make the decision to refuse particular treatment, in this case, sedation.

Further, we certainly don’t know if it was suggested that the treatment would cause ‘unreasonable’ distress to the patient, but what is ‘unreasonable’ has to take into account the need to transport the patient to hospital in an ambulance. The fact that it causes some distress may not mean the distress is ‘unreasonable’ in the circumstances. It must be noted that one of the criterion in either s 5B(2)(a) or (b), quoted above, must be met for the attorney’s refusal to be binding.

Finally, as noted above, even if there is a right to refuse treatment that does not give a right to demand treatment that is unwarranted or cannot be safely delivered without that treatment that has been refused. Just as one couldn’t insist that a doctor perform surgery without gloves, so too the attorney, who may be able to refuse sedation, cannot ‘demand’ that the patient is transported if the transport cannot be done, safely, without the necessary sedation.

Without these critical clinical details it’s not possible to be definitive but the discussion above, does help to suggest what the rights and duties of the paramedics were, or are.

The first point is that if paramedics are, and want to be, professional they need to engage, and be engaged, as part of the health care team. The nursing home staff can’t tell the paramedics how to do their job but they can and should deliver clinically relevant information to the paramedics to ensure that the patient gets the best possible care in accordance with their wishes. The paramedics need to understand why the nursing home staff are asking (not instructing) the paramedics ‘not to administer any treatment including sedation’ and should be willing to accommodate those concerns if they are clinically and ethically relevant. If there is, or was, a sound clinical reason for the request then the paramedics need to work with the rest of the health care team to determine what alternatives there are that would allow the patient to be transported in a way that meets their clinical needs and also ensures the safety of the paramedics and other road users.

Equally the attorney may consent, or refuse, treatment but they cannot insist on treatment. In the circumstances if there is no way to transport the patient without physical or pharmacological restraint that has to be communicated; it may come down to the fact that if the attorney refuses sedation they are in fact refusing ambulance transport! That cannot be used as a glib answer, ‘take what we offer or nothing at all’. As with the concerns of the nurses, the attorney’s concerns need to be considered and, if possible, accommodated, but if not possible then that too has to be communicated.

In short however, neither the nursing home staff nor the attorney can demand that the paramedics transport the person without sedation if sedation is clinically warranted and essential to ensure the safety of the paramedics and other road users. If they refuse that treatment and the refusal is valid then alternative transport or treatment would need to be arranged.