Comprehensive documentation provides a defence for Paramedics in a very contentious world. Without documentation, it is very hard to show that something occurred. Thorough timely documentation and the use of the VIRCA method should not be seen as additional and unnecessary paperwork. Instead, it should offer the Paramedic some peace of mind. It has been established at law that a Paramedic owes a duty of care to their patient. The QAS as an organization also owes its patients a duty of care.
As such, it is vital that the QAS perform their job professionally and correctly. This is because once a duty of care is established; the QAS has to ensure that they do not breach that duty. Virca Does not apply to case where transport is not required, but the documentation still needs to be completed with all Patient details and applied management and advice given.
Patients who refuse transport. There is still a concern amongst Paramedics that they have no defence against negligence apart from transporting every person they attend. In some instances this has not been the case. Documentation provides a defence; and as such, documentation is an integral part of the treatment for each patient a Paramedic attends. It is an established legal truism that a person of sound mind has the right to self-determination; they can choose what is done (or not done) to their body.
The voluntary choices and decisions of an adult person of sound mind concerning what is or is not done to their body, must be respected and accepted, irrespective of what others, including doctors, may think is in the best interests of that particular person. The difficulty arises when there is doubt over whether a person is of sound mind. However, in cases where the person does have an adequate mental capacity, a patient does have the right not to be transported. As such, Paramedics need not fear the worst if they are faced with a patient who refuses transport. Instead, they need to have a good understanding of the legal principles behind patients who refuse transport, and its correct documentation. This leads to the next section.
Method for Correct Documentation for Non-Transport E-ARF’s – VIRCA The correct method for documentation where a patient refuses transport is to use the VIRCA acronym. V – Refusal must be made voluntarily. I – Pt must be informed of their condition, and risks associated with that condition if they are not transported. R – Refusal must be made relevant to the circumstances. C – Pt must have the capacity to refuse. A – Pt must be provided with sound discharge advice. Every time a Paramedic attends a patient who refuses transport, it is necessary to document that fact by using the VIRCA method. Each element needs to be addressed separately and applied to the particular circumstances of the individual case.
How to Integrate Patient Assessment and VIRCA. Having examined each element, there is a need to look at the big picture of patient treatment where the patient refuses transport. As per a memorandum from the Commissioner, a Paramedic should:
1. Assess the patient systematically whenever possible. Of course, sometimes a patient may be aggressively non-compliant, and a full assessment will not be possible. However, even from distant observation a Paramedic should be able to assess some areas. For example, obvious external haemorrhage, incontinence, inappropriate behaviour or language, forced respirations can all be obtained from a patient at a distance. All these findings need to be documented.
If possible, try to establish a provisional diagnosis from these findings. Also, don’t forget to obtain history from the patient’s friends, QPS, or from bystanders. They may be able to give a Paramedic a very useful rundown of events, which can help in assessing the patient’s condition. Advise the patient. Inform the patient of your clinical findings, and suggest to them your provisional and differential diagnoses. Make sure they understand the information you are providing them with, as this forms part of the assessment of their capacity to refuse treatment and/or transport. The next step is to inform the patient of the potential risks inherent in them not being transported to a medical facility. It is important to be realistic, or the patient may not believe you.
It is very rare, that people will die for trivial complaints but this may cause the patient to doubt your credibility if you seem to over communicate the condition they have if only minor. It is better to provide the patient with more realistic examples of what may happen, and then conclude with the possibility, even if unlikely, that paralysis or death may result. Please note that if a injury or illness may lead to death, however unlikely, then you must inform the patient of this. The point is to be sensible when explaining it, or the impact may be wasted, and the seriousness of the situation be replaced with incredibility.
3. Assess the Validity of the Refusal. To assess the refusals validity, simply apply the VIRCA acronym. Other Alternatives. If the patient is not compliant with the advice of QAS officers, consider other alternatives. If the patient will not go to a hospital, does he have a family doctor that will come to see him? Could family members be used to help convince the patient of the necessity to receive transport? If necessary, consider the use of QPS in assisting with transport, especially patients that may come under the Mental Health Act provisions.
Document thoroughly using VIRCA. Having completed all other steps, it is now necessary to document all the above steps to paper. Complete an E-ARF as per the CPM guidelines, including a provisional diagnosis. The E-ARF should be completed with the same care as for any other patient, notwithstanding that the patient may have already left the scene. Include in the E ARF each of the VIRCA steps, and apply them to the circumstances of the case. See the applied example in the next section for a practical application of this.