Irish legislation on Advance Healthcare Directives (Assisted Decision Making Capacity Act 2015, ADMC) proposes to change the basis of decision making from acting in the patient’s best interests to following the expressed will and intentions of the patient. Refusal of life-saving care can occur, without sound reasons. The implications for care in life-threatening emergencies have not been explored among clinicians.
An anonymous questionnaire survey of Advanced Paramedics (AP) covering awareness of the legislation, attitudes to and experience of refusal of care and potential actions in emergency scenarios now and if the legislation were in force. The scenarios covered end-of-life and deliberate self-harm situations potentially requiring resuscitation.
All 482 graduates of the Advanced Paramedic Training Programme were invited to take part.
Overall, 85/389 (21.9%) valid contacts responded, with demographic characteristics similar to the overall population. Attitudes ranged from highly positive to highly negative in relation to the potential impact of the legislation on professional and operational responsibilities. Respondents described marked changes in whether they would offer resuscitation if the ADMC were in place.
Irish legislation which changes the traditional basis of medical practice away from the best interests of the patient may affect the resuscitation practices of Advanced Paramedics in life-threatening situations. It has significant implications for medical education, professional practice and clinician-patient interactions. This legislation and similar planned legislation may have implications for other EU jurisdictions.
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All study participants provided informed consent.
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Article summary—strengths and limitations of the study
• Ireland is changing its laws to require the patient’s ‘will and preferences’ to dictate care instead of the clinician’s perceptions of the patient’s ‘best interests’.
• Refusal of care can occur, even if this leads to death.
• First research to explore the impact of these changes—survey with low response rate but key provider group.
• Advanced Paramedics report significant potential changes in resuscitation practice, in key scenarios.
• There may be implications for practice elsewhere in the EU.
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Bury, G., Thompson, A., Tobin, H. et al. Ireland’s Assisted Decision Making Capacity Act—the potential for unintended effects in critical emergencies: a cross-sectional study of Advanced Paramedic decision making. Ir J Med Sci 188, 1143–1148 (2019). https://doi.org/10.1007/s11845-019-01994-w