Paramedic and Family Decision-Making During an Emergency Ambulance Response to an Acutely Unwell Child: A Qualitative Case Study

Abstract Introduction Emergency calls involving children are common, yet are frequently self-limiting rather than life-threatening illnesses. Paramedics are well-positioned to manage these situations, but policy constraints, limited child-specific training, and parental concerns can influence decisions. Despite increasing autonomy, paramedics must navigate uncertainty without clear, evidence-based pathways for managing acutely unwell children outside emergency departments, making this an important area for research and reform. Aim The research explored how English paramedics and families make decisions during ambulance encounters with acutely unwell children, and what clinical and ethical factors influence the decision-making process. Theoretical-Framework A dual theoretical framework underpinned the study: Dual process theory, specifically the heuristic-analytic model with abductive logic, and Principilism, including parental autonomy, child interests, and justice, to examine the cognitive and ethical dimensions of decision-making with children. Methodology Initially designed as a case study of paramedic-family encounters following a single-site English ambulance service callout, recruitment challenges necessitated dissociating cases into distinct participant groups to bolster the single-case study encounter. New strategies included opportunistic recruitment through primary and urgent care settings. The study incorporated policy document analysis and qualitative interviews with paramedics (n=10) and families of children aged five years and under (n=10). Two children spoke about their experiences when given the opportunity during the family interview. Data were analysed thematically using a combination of in vivo coding, belief analysis, and narrative schema, particularly for the child’s perspective, which incorporated drawings. Themes were asserted through a meta-matrix, which derived a visual perspective of the decision-making process. Results Families sought healthcare when their child showed behavioural changes unresponsive to home remedies. Parents used 111 when uncertain, and 999 if they felt their child’s condition was life-threatening. The 111-999 cascade triggered parental guilt or frustration at being caught in a risk-averse system. Paramedics followed a four-stage decision-making process: 1) initial heuristic impression; 2) analytical exclusion of red flags; 3) dichotomy; and 4) abductive reasoning to reach a final decision. Clinical exposure to unwell children improved confidence in discerning critical illness and safe non-conveyance. Decision tools confirmed rather than challenged clinical assumptions. Parents perceived involvement in decision-making, yet paramedic authority subtly steered outcomes with candid truth-telling regarding scope limitations. The mandatory conveyance policy for children under one year disempowered clinicians and families, causing unnecessary transport and uncomfortable consequences for the family. Though children were silent in the decision-making context, failure to establish child rapport often resulted in a pro-conveyance decision. The two children interviewed perceived paramedics as authority figures who "tell" or "take" people to the hospital. Partners and crewmates also influenced the decision, highlighting the importance of relational dynamics and identifying who is the primary decision-maker on the scene. Conclusion Paramedic care for acutely unwell children involves complex judgement, ethics, and relational factors to ensure safe decisions despite uncertainty. However, age-based policies override clinical reasoning and undermine family-centred care. Ambulance services should revise paediatric policies to empower paramedic judgement, supported by robust frameworks with senior clinical support. Alternative dispositions to conveyance may be more ethically sensitive. Improving rapport and involving children in decisions could enhance family satisfaction and care quality.