In these daunting times it is understandable that many of you will be thinking about the decisions you will be making, the efficacy and safety of those decisions and the consequences once they’re made. Equally within the current climate; the concern about the higher risk some of these decisions may bring. This is an understandable concern and the hallmark of a reflective and conscientious practitioner.

Some of you may not be feeling prepared or confident in your own ability, and this is important to recognise. Most practitioners have an awareness of the things they do and don’t know, but part of decision making is being aware of "unknown, unknowns" in our own knowledge. I am always reminded of a key quote by Donald Rumsfeld, Former US Secretary of Defence who summarised the work of Luft and Ingham (Luft, 1969) stating:

Having the awareness that we all have things that we actually aren’t aware we don’t know about, is key to all clinical decision making. Even the most experienced GP's will be aware of this phenomenon, and yet they’re expected to manage a full range of disease and illness without specialist knowledge in the fields they practice in. A phenomenon I like to describe as the 'specialist generalist'. Paramedics equally fall into this category, so how do we safely manage all those patients when we're unsure of what is going on?

No decision is without risk; how we manage that risk is key to ensuring safety of the patient and equally as important, our ability to sleep at night after the decision. The current climate is likely to require us to make atypical decisions in areas we were never really exposed to in general paramedic education.

As practitioners we are fearful of blame and this consequently makes our practice defensive (Kirk et. al., 2018); however this defensiveness often leads us into making decisions that are right for the practitioner but not always right for the patient and could lead to unintended clinical harm. A key way to conceptualise this is: Is this decision the best for my patient, or is it the best for me? What drives that 'just in case' decision is often driven by our fear of missing something, however, the overriding factor should be:-

At this stage it would be useful to consider a common clinical example:

This is a common clinical scenario and one that is seen in Emergency Departments around the UK, with patients admitted after a history of increasing falls.

Do you take her to hospital? It would be useful in dissecting the clinical rationale for the decisions looking at the immediate and future consequences of the decision.

In the short term the decision to take her into hospital so she can’t suffer any more falls seems reasonable . This is likely a decision that is made to mitigate the clinician against any accusation of harm from future hypothetical falls, and often manifests due to defensive practice - those decisions deliberately chosen to protect the healthcare professional.

"Great!" I hear you cry this lady is protected from immediate further falls, and thus won't face questioning/complaint should she have a further fall after our attendance.

However, after admission to the Emergency Department she has had extensive tests which have found nothing acutely wrong medically, but the care team feel it is too late to discharge her and she is admitted. She then develops a hospital acquired pneumonia and spends a week at hospital. Unfortunately, her mobility has dramatically declined due to muscle atrophy from bed rest as she was not mobilised in hospital. This has now led to her being admitted to a care home, which she does not enjoy and desperately wants to return home. Despite best efforts of the care home staff this becomes increasingly unlikely as her mobility doesn’t improve and she will likely have to remain in full time care!

Whilst this decision is clearly 'safest' for the crew, it is unlikely in the best interests of the patient. The likely bias of crew concerned is that if she were to fall again and injure herself they may face disciplinary action, so admitted on a 'just in case' decision (Fitzgerald & Hurst, 2017). In the short term this reduces harm from further falls, but in the long term the unintended consequences have a long-term impact on this patients life and independence (Seden, 2016). Equally, was the patient aware of the risks of hospitalisation in line with the Montgomery principles? (Montgomery v Lanarkshire Health Board, 2015 - this will be explained later in this thread)

So what's the alternative?

Whilst initially the defensive practice mitigates the risk of further falls and injury which the crew were worried about, it in fact leads to more harm in the long term for the patient. Defensible practice whilst similar has the opposite intention. This is where the decision is made using a reflective and critical framework with the patient at the centre of the decision. It identifies the risks to the patient and puts appropriate mitigation of those risks into effect, allowing the patient to make an informed decision based on those risks and medical opinion.

In our scenario the crew identified no immediate risk or medical need, however, are concerned about the potential for further falls despite the patient walking well presently. Whilst the crew have identified she needs help, this does not need to be immediate and there is nothing an Emergency Department will be able to tangibly add through admission tonight, and the crew are rightly concerned admission would not be in her best interests due to no acute medical need vs. the risk of hospital acquired illness / morbidity and mortality.

Through the appropriate mechanisms they arrange for the GP to review the need for ongoing blood pressure treatment (as long term benefits of BP control may be outweighed by the risk of falls related to blood pressure control in the older person – and stopping may reduce the falls), the GP may undertake routine bloods to assess for any obvious metabolic cause for the falls. A referral to occupational therapy or rapid response team will activate community intervention to mitigate further risk of falls and empowers the patient to remain in her home and independent.

Whilst the defensible practice may leave the crew open to complaint if she sustains a further fall, this should not impact the decision to provide reasonable treatment. The decision is defensible in that the patient has been provided appropriate care to protect against actual risk of increased frailty from an inappropriate hospital admission and exposure to hospital acquired infection or immobility, which can be completely avoided. The risk of potential further falls has been mitigated by prompt referral and worsening advice to the patient in the event of further falls, or becoming unwell. This does not mean a further fall won’t happen, but as a clinician you have put reasonable steps in place to safeguard the patient. That does not mean you have to do something immediately, but that things will be done in a reasonable time frame. Equally, your decision not to convey to hospital is supported, as the risk of complications from admission is high, against the hypothetical risk of further fall and injury and the fact that community services are better placed to deal with this situation (Seden, 2016). Ultimately, the patient understands the risks communicated and agrees and would prefer to remain at home in light of this discussion. Documenting decision making is explored later.

We can explore how this applies to medical ethics, which is used as the corner stone for evaluating the quality of medical decisions:

The basis of ethics are based around these four principles

These principles guide clinical decision making. I hope that you can notice in these four ethical principles, there is no mention that you must do everything the same, for every person, all of the time. Essentially your decision is based around the patient you have in front of you, the resources you actually have available, the patient’s wishes about that treatment, and even if that treatment may be indicated, is it necessarily best for your patient?

Let’s break it down into genuine thoughts you may have around a complex decision where the plan may not meet expected guidelines; using our example from above.

No paramedic I know willingly goes to work to do harm to a patient, this does not mean it won’t happen at some point. Equally that doesn’t mean we should practice defensively or reactively as no clinical practice is without risk; even taking a patient to hospital is a balanced decision.

With the patient above, the defensive practitioner was concerned about further falls; therefore took the lady into hospital so that she wouldn’t be at risk of further falls again – fantastic short term, she is safeguarded from a hypothetical risk that she may fall and an even smaller risk she may suffer significant injury from the fall.

However, we have now exposed this patient to a higher risk of acquiring a hospital acquired infection and atrophy of her muscle from bed rest.

To do no harm means we should be protecting patients from the most likely risks of their condition and often that decision is easy:

e.g. taking the patient with a myocardial infection confirmed by ST segment elevation on an ECG who is having central chest pains, as leaving them at home they are likely to go into cardiac arrest and die or have significant heart failure afterwards if untreated.

However, with our lady above there are risks to both decisions. You need to balance the risk of the action vs. the likelihood of it happening. It is reasonable to surmise that whilst there is a risk of further falls, this can be safely managed in the community and whilst there is a risk of significant injury, likelihood is low and the community intervention that can be put in place which mitigates this risk.

Conversely, with admission to hospital there is a known risk and likelihood of muscular atrophy and further reduced mobility, there is also a risk of a hospital acquired infection; there is no way to mitigate this risk if admitting as the patient is likely to be managed by bed rest and will be exposed to other patients during their stay.

As such the decision with the least risk, will be to manage in the community and these risks can be discussed with the patient to allow them to make a reasoned decision based on the information you have given.

Patients need to be involved in these decisions, they want to have control over the direction in their lives, even if we find those decisions unreasonable, or foolish (where they have mental capacity to make those decisions) they have the right to make that decision for themselves.

For our lady above, we know this patient is very keen to remain independent and at home; there is no overriding clinical need to take her into hospital, and to do so would be disregarding this lady's thoughts and values of the situation.

Management of the risk of further harm will be individual – in the case above this lady was happy to accept the risk that she may have further falls and was keen to manage the situation at home, we also know this is clinically reasonable and probably the best treatment pathway for her.

However caution must be taken, whilst we are aware of what the most optimal plan will be, patients must have the options explained to them and the risks and benefits for each decision explained in a manner they understand. A recent test case (Montgomery) found that patients must be informed of all of the options available to them for treatment. We can still provide our clinical judgement on the situation to aid their decision.

This is the area of ethics that normally gets misinterpreted and paramedics often feel hamstrung that 'acting in best interests' means doing the most optimal treatment for the patient that avoids any immediate harm. This is not possible in medical care and a balance of the risk, versus the benefit, where possible in collaboration with the patient, is the ultimate aim.

In the case above, continuing to leave this lady at home does increase the risk of having a fall and possibly being injured – however this is outweighed by the risk of admitting to hospital where it is more likely she will end up having significant muscle atrophy from being managed in bed.

Whilst ideally in the short term we would like to completely prevent the fall happening by not leaving at home, we can mitigate this risk by community services geared up to managing falls (and this doesn’t have to be arranged immediately at that point in time by the clinician) such as occupational therapy and community physiotherapy. Thus we have done the best reasonable care to manage this patients complaint and have been proactive not reactive in their care. Best care does not have to happen immediately after your intervention, as long as it has been arranged and the patient is given robust worsening advice; this would be seen as reasonable 'best interests' care.

Now this is commonly where quandaries lie, in that optimal care isn’t immediately available because those needing the care outweigh the resources that deliver that care. This includes hospital specialists, community care and general practice. It can be hard as a paramedic to accept that something can’t immediately be done. Equally we become fearful of complaints if something can’t be legally done. However, you will not be criticised for managing patients with the resources available to you.

For our lady above, a community team are unlikely to be able to assess this patient immediately after your assessment, equally at 4am you are unlikely to make a direct referral. However, an electronic referral either through GP or directly (if your service enables) would be reasonable as further action wouldn’t be needed immediately.

Sometimes services may not be available or the patient may not be eligible, e.g. emergency care packages. This does not mean the patient needs to be taken to hospital if it is not in their best interests. It is unlikely an emergency department is going to be able to do anything different and equally would have no further access to services, which you could not access also. It may be necessary to apply other measures to safeguard or manage the situation after you have left e.g. referral to patients own GP.

In summary: you will not be penalised for doing the best you can for the patient, taking into account the patients wishes and you have clearly explained the risks to the patient. You will not be penalised for making a decision that you feel causes the least risk for the patient with the resources you have available at the time of the assessment. You do not have a crystal ball, and you are not expected to make resources magically appear.

Hopefully you can see that by assessing the situation, making reasoned decisions and documenting your rationale gives you a DEFENSIBLE position to treat your patient, over a DEFENSIVE action that may not be best for the patient but best for the clinician e.g. taking to an Emergency Department solely to defer the clinical decision to another healthcare professional.

As long as your decision is rational, with the patient at the centre of the decision who is also engaged with that decision, then your position is reasonable and defensible if that decision is ever queried or a complaint arises. This is not to mean that there is not learning to be undertaken if there is an untoward event, but your decision can be supported based on the facts available to you at the time.

I found a useful analogy which summarised clinical decision making and how you should think when weighing up the risk vs. benefits:-

There will be undoubtedly times where you aren’t sure what to do. Equally this does not mean you should default to the least risky option (often conveyance in the ambulance service setting) where you cannot confidently identify the pathology going on.

It may sound bizarre but you need to be comfortable with ambiguity and sometimes not knowing immediately what is going on. Not being comfortable, means you are likely to feel more stressed and open yourself up to burn out.

It is okay not to know. I am a clinician with over 10 years’ experience in emergency and primary care and there is still lots of things I come across that I don’t know; this is the same for my General Practitioner colleagues. The reason we are still here doing what we do is that we have developed strategies to manage the unknown. Often symptoms require time to diagnose and/or a diagnosis does not become apparent until thorough testing has been completed. Investigation over time and sometimes watchful waiting (the principle of leaving symptoms until further development or resolution) allow us to put the pieces together and make a diagnosis. Occasionally the patient gets better without ever having a formal diagnosis.

To be a competent practitioner we need to be confident that we have excluded immediately sinister pathology to be confident immediate action is not required. This comes from a good understanding of clinically pertinent symptoms; commonly known as 'red flags'.

Managing risk due to uncertainty in ambulance practice is vital, we deal with patients that are risky (as often presentations are new and acute), and mostly unknown to us due to no access to their previous history and current management plan. This does not mean this risk cannot be managed, by developing comfort in identifying those pertinent red flags which are generally symptoms which require acute assessment, often within the next twenty-four hours. Often where these pertinent symptoms and signs aren't present then routine investigation can be made by the patients usual healthcare provider. This comes from undertaking a comprehensive history and physical assessment of the patient.

Sometimes the exception to this is where patients are under current specialist care, where symptoms of worsening can be unusual. These patients, however, are often experts in their care and often have access to robust care plans that can be followed, it is always useful to be on the lookout for these.

Unless you are sure of the diagnosis yourself, and have the skills to manage that diagnosis, you should ensure the patient has been referred for further care or investigation for that condition. Either through direct referral (speaking to the appropriate healthcare professional on the phone, who agrees to manage the patient, or indirect referral, where an electronic or paper request for assessment and management is made. There is no rule for which is appropriate, however where you feel assessment is needed urgently a telephone conversation is normally the safest avenue to refer.

Excellent further reading can be found here in relation to managing uncertainty: https://patient.info/doctor/coping-with-uncertainty-in-primary-care. Overall, a significant number of presentations can be managed without hospital admission and undertaken by the expertise already available in primary care. Hospital admission is not without risk. You should understand the risks of admission to hospital and these risks should be explained to the patient, especially where their expectation was to attend hospital but from your assessment you do not feel this is required.

Remember, your confidence will grow in these decisions, what is common is common. You are expected to managed the situation you have in front of you. No one is expecting you to have a crystal ball and foresee every possible avenue, however you do need to safeguard against a change in the clinical picture and ensure the patient understands how to access help should symptoms develop, change, worsen or the current treatment is not working.

This video succinctly explains uncertainty and conceptualises how to manage your thought processes around uncertainty.

Sinister disease generally tends to come with its own red flags and when something needs to be managed urgently. We tend to know most of the common ones already.

Symptom Sorter by Keith Hopcroft and Vincent Forte is an essential text and I recommend you have a look if you have not already. It is a useful text to keep in your grab bag when you’re wondering if this symptom is worrying or not, for particular condition. Whilst red flags usually need prompt referral – this does not necessarily equate to admitting the patient immediately, some may require an urgent referral to a specialist within a set period of time, some may require further urgent investigation by the patients GP.

In the absence of red flags you can be generally reassured that nothing acute needs to be completed at this time, which gives you time to develop a plan. This can be in conjunction with the patients GP or another healthcare provider and allows time for community testing and assessment of the illness - forgoing admission.

But what about those patients that have red flags but don’t need referral or don’t have any red flags, but you are still not sure what is wrong with them? Or you have a tricky decision about treatment that may go against guidelines?

Don't worry, there is always a friend to call and we will go onto clinical advice and shared clinical decision making next.

Clinical advice is an excellent source of help with difficult decisions. Experienced clinicians have made many complex decisions and often have well established strategies for managing risk in clinical decision making. There are various sources including Ambulance Service senior clinical advice lines, specialist practitioner support in clinical hubs/control centres. General Practitioners and other healthcare professionals and services can provide advice within their specific areas of practice, but should not be used as a generic place of support and so should be used if the patient will directly benefit from their expertise or input.

The overriding principle of remote clinical advice is:-

However, you can use the advice to support your ultimate decision. Try to use advice within your own service, the GP is not a surrogate clinical advice line. Sometimes the GP will be useful to make a collaborative decision, where your plan is to manage the patient at home. The patient's normal GP will have access to their full medical history and often there is a plan in place already to manage their conditions. This will also mean follow up care is likely to be more streamlined. Remember, other services will equally be as stretched so try and ensure that direct referrals (e.g. clinician speaking to clinician) are done where ongoing care or information about their present medical care is needed. Otherwise, indirect referral via email or referral pathway may be more appropriate.

Ultimately, shared clinical decision making is the corner stone of safe clinical practice, especially where decisions are complex or where normal guidelines may not be appropriate to adhere to e.g. stepping outside of JRCALC guidelines for the patient’s best interest. This opportunity to explain your decision to someone else, allows another clinician to add another opinion on the situation and highlight another way of approaching the situation. Alternatively, it provides the confidence that the decision is reasonable and that another one of your peers would make a similar decision if faced with the same circumstances.

This principle should not be confused with shared clinical decision making, where decisions are discussed practitioner-to-practitioner on the basis of gaining additional clinical opinion (either peer or expert) from another colleague.

Shared decision making is the concept of the decision being made jointly between the healthcare professional and the patient involved, and where possible the final decision should be jointly agreed, with the patient having been informed of all reasonable potential diagnosis, treatment plans available and the risks around those plans (including how those risks can be mitigated).

This concept of a collaborative approach is more crucial in contemporary practice from a recent ruling in a High Court case; Montgomery vs. NHS Lanarkshire (2015). This ruling enshrined in law that when making your decision on treatment this must be done in collaboration with the patient and they must be informed of all the material risks that decision (either by accepting or declining treatment) may entail. They must be a part of the decision making process, where they have the capacity to make decisions regarding their care and treatment.

This ruling does not mean patients have to be offered treatment that is clinically inappropriate, but must be made aware of all reasonable options that are clinically applicable.

• This does not mean that you are required to discuss all options available if they are not all appropriate/reasonable in a particular patient's case

• You are not expected to be able to offer any and all treatments that can be found globally/in research settings

• If a patient requests a treatment/procedure that you do not think is a reasonable or appropriate option, you can refer on to another clinician for a second opinion

Royal College of Physicians and Surgeons of Glasgow

In summary, the principles of your decisions should be based on the best interest, balancing the risk of treatment with the likely overall benefit, done in cooperation with the patient (where possible), with the resources you have available at the time. This then constitutes a reasonable, defensible decision.

Within UK statute there is no legal requirement to provide treatment a patient demands where the treatment is not clinically indicated (either through basis of clinical guidance or due to the level of risk to the patient). Equally, Graber and Tansey (2005) reasonably argue that by demanding treatment (some that may be more expensive) brings inequality into the system, by depriving others that fundamentally need this care e.g. no ambulance being available as conveying a patient to an emergency department who clinically did not need to be there.

What does that mean for practice?

You are not obliged to provide treatment for a patient where this is not clinically required. If in your assessment you do not feel that a patient requires conveyance to hospital you are not legally obligated to.

Clearly you must ensure that you have provided every opportunity to find a compromise to the situation as this will often diffuse the situation. Empathy is your biggest tool here, and exploring the rationale as to why they are demanding a certain treatment/course of action will often allow avenues to explore alternate treatment (which is often more appropriate for them than what they were originally expecting) - people often want speed of treatment and as such believe Emergency Departments can deal with this. By addressing this, it allows for negotiating other more appropriate treatment/s or options for them.

If you are at an impasse and are happy you have explored all practicable solutions, then this should be documented clearly. Do not provide the inappropriate treatment, but ensure the patient is aware that they can always reconsider the help offered. Do provide the information on how to access this, with the usual worsening care advice.

Medical Protection Society (2018)

Coronovirus / Covid-19 (SARS-CoV-2) is indeed placing unprecedented demands on the healthcare system. It is understandable that you may be apprehensive about those decisions.

It is likely that the decisions you make will need to be made outside of that expected within usual practice. You will feel that these decisions will go against your normal desire to do the most for patients. However, these decisions will be made to maximise the availability of health resources and to reduce the risk of exposing vulnerable patients to infection risk.

As we discussed above decisions to convey or admit patients to hospital are not without risk. There will be patients who fall into the high-risk category for infection.

It may be that whilst your normal practice would be to take a patient to hospital, the new increased risk of contracting coronavirus may impact this decision. It is likely to mean you would like to consider managing more patients at home. Equally, some patients may now, not benefit from hospital admission.

Do not feel alone in these decisions as they will be taking place around the country, equally you have support, make sure you utilise access to clinical support. Remembering the foundations discussed above will help support your decisions in these difficult times.

Ensuring you document how you came to your decisions is as vital as recording the decision itself, remembering this documentation will be what you will use to recall your decisions in years to come.

Equally this rationale is useful for anyone involved in the patients ongoing care to understand why you made the decision at the time and reduces the risk of misunderstanding between healthcare professionals. It allows effective ongoing care of the patient.

This is vitally important where it is decided certain treatments won’t be undertaken. Firstly, it demonstrates your understanding of the available care pathways and treatments; secondly it clearly shows your rationale as to why/why not undertaken.

Worsening care advice (for referred patients) should be clearly documented, including specific instructions for what to do when things go wrong e.g.

“If breathlessness worsens, develops any haemoptysis or chest pain the patient has been advised to dial 999”

What would not suffice is “usual worsening care advice given” as this does not demonstrate what advice you gave to the patient.

In summary, the documentation is not there to cover your back, but to convey your thought processes for why you did or did not do something for a patient.

· Decisions are made in the best interests of the patient – this may include not to undertake a treatment (that may be usual for the condition being treated) as may this cause more harm to that patient at that time.

· Decisions are made based on the circumstances, presentation and available resources at the time; what is right in most circumstances may not fit all circumstances.

· Patients should be at the centre of all decisions. Whilst you are not obligated to provide a treatment, patients may decline treatments; shared decision making between the patient and the healthcare practitioner are vital to ensure safe and reasonable decisions are made. Patients must be aware of all the treatment options reasonably available to them and risks of each option explained.

FitzGerald, C., Hurst, S. Implicit bias in healthcare professionals: a systematic review. BMC Med Ethics 18, 19 (2017). https://doi.org/10.1186/s12910-017-0179-8

Graber, M.A., & Tansey, J. (2005). Autonomy, consent, and limiting healthcare costs. Journal of medical ethics, 31 7, 424-6 .

Kirk, A., Armstrong, K., Nurkka, N. & Jinks, A. (2018). The impact of blame culture on paramedic practice: A qualitative study exploring English and Finnish Paramedic Perceptions. International Journal of Emergency Services, 7(3), pp. 214-227.

Luft, J., 1969. Of human interaction. Palo Alto: National Press Bookds.

Medical Protection Society (2018) Doctor's orders vs. patient choice. [Online] Available at: https://www.medicalprotection.org/uk/articles/doctors-orders-vs-patient-choice [Accessed 14 April 2020].

Montgomery v Lanarkshire Health Board [2015] SC 11 [2015] 1 AC 1430

McCullough, L. B. (2013). The Professional Medical Ethics Model of Decision Making Under Conditions of Clinical Uncertainty. Medical Care Research and Review, 70(1_suppl), 141S-158S. https://doi.org/10.1177/1077558712461952.

Royal College of Physicians and Surgeons of Glasgow (Undated). Advice post-Montgomery [Online] Available at: https://rcpsg.ac.uk/college/this-is-what-we-stand-for/policy/consent/advice-post-montgomery. [Accessed: 14 April 2020].

Rumsfeld, D. H. (2002). DoD News Briefing - Secretary Rumsfeld and Gen. Myers. [Online] Available at: https://archive.defense.gov/Transcripts/Transcript.aspx?TranscriptID=2636 [Accessed 06 April 2020].

Seden, J. (2106) ‘Social work: risks, needs and balanced assessments’, K216 Readings, Milton Keynes, The Open University.