VACEP EBM Series: Paramedics delivering palliative and end-of-life care in community-based settings
VACEP’s Evidence-Based Medicine Review Series
for Emergency Physicians
Authors: John Mallow, MD & Martin Payne, MD (Riverside Regional Medical Center, Emergency Medicine Residency Program)
Reviewer: Joshua Easter, MD, MSc (UVA Health)
Article: Paramedics delivering palliative and end-of-life care in community-based settings: A systematic integrative review with thematic synthesis.
Authors: Madeleine L. Juhrmann, Priyanka Vandersman, Phyllis N. Butow, Josephine M. Clayton
About the EBM Review Series
VACEP’s Evidence-Based Medicine Review Series is a monthly literature review started by the University of Virginia’s Josh Easter, MD, MSc, a VACEP board member working to connect the academic community in Virginia. Physicians and residents submit their review of a recent journal article, and their summary is reviewed by emergency physician peers and published here. We invite each residency in Virginia (and D.C.) to create a faculty/resident team to submit and review articles. Email VACEP communications director Jeff Kelley to take the next step.
Goals
Provide a brief monthly synopsis of a high yield article germane to the practice of emergency medicine for distribution to all VACEP members
Provide an opportunity for a peer reviewed publication and invited presentation for faculty and trainees
Foster an academic community focused on evidenced based medicine for emergency medicine residency programs in the region
CASE
A 75-year-old female presents to the emergency department with severe abdominal pain, nausea, and vomiting. In the field, paramedics report that patient has ongoing palliative care and is close to end of life from stage IV metastatic colon cancer. Family attempted to call the patient’s palliative care team, but as patient’s symptoms began at 0100, after specialty service hours, they were unavailable. Her family is concerned due to her severe symptoms and want her sent to the emergency department for symptom control and further evaluation.
Could pre-hospital personnel have prevented a potentially unwanted, avoidable, and potentially costly emergency department visit and possible hospital admission?
REVIEW
Global demand for palliative care is increasing, with the World Health Organization estimating that approximately 40 million individuals require palliative care yearly (World Health Organization, 2020). Specialty hospital-based care providing such services is unsustainable.
Furthermore, international research shows that two-thirds of individuals want to die peacefully at home (Gomes, 2012). Pre-hospital personnel are in a unique position to help deliver palliative and end-of-life care, especially after-hours when a major coverage gap exists. However, though these professionals have training in providing life-sustaining interventions in emergencies and conveyance to hospitals, many have little to no training in management of palliative-care emergencies (Long, 2019).
M. Juhrmann et al. performed a systematic integrative review of all existing empirical studies (5,985 articles) regarding pre-hospital personnel delivering palliative and end-of-life care in community-based settings. They wanted to answer the following:
What is the scope of pre-hospital personnel delivering palliative and end-of-life care?
What are the perspectives of stakeholders involved in pre-hospital medicine on delivering palliative and end of life care?
What are the barriers and enablers for pre-hospital personnel delivering end -of-life care?
Thematic analysis was performed on qualitative data from the 23 studies that met inclusion criteria. In the analysis, patterns and relationships between each qualitative study were compared and contrasted and merged into themes. Quantitative data was then integrated with an integrative synthesis approach (Whittemore, 2005), to which three main themes from the data emerged:
Broadening the traditional pre-hospital paramedic role to include palliative care,
Understanding patient wishes; and,
Supporting families.
All but one of the included studies touched on the theme of broadening the traditional role of pre-hospital personnel to include palliative and end-of-life care.
There is a strong desire among ambulance staff, patients, and families for paramedics to refocus their attention to home-based palliative care rather than hospital conveyance. The studies highlighted enabling factors for broadening the traditional paramedic role, including increasing time on-scene, strengthening communication and support channels with multidisciplinary teams, and expanding palliative care training and education offerings to paramedics.
A look at the studies
One study explored paramedics without access to 24/7 palliative home care services but with end-of-life care at home protocols, including pre-planned integration of paramedics. It found 33% of patients in areas with this type of service experienced hospital-based deaths, compared to 54% of patients in areas without such a service.
Another study piloted an educational program for paramedics which included additional training in end-of-life and palliative symptom identification and management, creating a paramedic-driven palliative care service. It found 90% of patients receiving after-hours care by paramedics avoided hospitalization.
Two studies in the analysis were compared regarding extending the scope of paramedics in palliative and end-of-life care and preventing unnecessary ED visits. One had a paramedic driven end-of-life protocol for palliative care at home, while another lacked such a protocol. It was found that the study with the protocol transported patients with palliative emergencies to the ED 14% of the time, compared to 99% of the time in the study lacking such a protocol.
Other studies included in the systematic analysis supported these findings of broadening the scope of paramedics in palliative and end-of-life care. It was also found that paramedics providing effective palliative care resulted in increased professional satisfaction.
“Pre-hospital personnel are capable of filling in the gap in palliative and end-of-life care to people in their homes, especially after-hours for palliative emergencies. They can facilitate the important roles of home-based death and reduce avoidable hospital admissions. However, integration of palliative care and end of life services, education, and practical training into paramedicine is needed to create and provide optimal care. ”
Seventeen of the included studies reported that the theme of paramedics understanding patient wishes was of high importance for them to provide quality palliative care in the community setting. Field-based interpretation of documented patient wishes was identified as a source of difficulty in providing quality care. Accessibility, illegibility, incompleteness, and untimely access to these documents also presented challenges. This often resulted in paramedics initiating invasive treatment and transportation to the ED.
One study also identified access to electronic health records with up-to-date information and clear palliative care team details as a solution to these barriers.
The family variable
The last identified theme was providing more support to families. Partnering with and recognizing families as key decision makers was found to be integral by paramedics in providing palliative and end of life care. Clear communication of care options was key to achieving better outcomes for the patient and prevent avoidable hospitalizations and unwanted resuscitation. Families themselves felt peace of mind when paramedics were strong communicators and respected patient’s goals of care.
Contrastingly, family discordance was identified as a major barrier to providing palliative and end-of-life care, especially regarding inconsistent expectation of outcomes between family and patients during palliative care emergencies. A major contributing example includes families calling ambulance teams to stop the dying process of their loved one, despite a palliative diagnosis and pathway already existing.
Paramedics and pre-hospital teams can fill the palliative gap
Juhrmann et al. concluded in their study that pre-hospital personnel are capable of filling in the gap in palliative and end-of-life care to people in their homes, especially after-hours for palliative emergencies. They can facilitate the important roles of home-based death and reduce avoidable hospital admissions. However, integration of palliative care and end of life services, education, and practical training into paramedicine is needed to create and provide optimal care.
There were several key limitations. Multiple of the included studies had small sample sizes, increasing risk of sample bias and reduced the likelihood of saturation of the identified themes. Many studies were qualitative in nature and did not quantify effect sizes.
CONCLUSION
Your patient with stage IV metastatic colon cancer is discharged from the emergency department after symptom control. One week later she has recurrence of severe abdominal pain, nausea, and vomiting again at 0100. The paramedics, now educated and integrated with a palliative care service and protocol in place, were able to achieve adequate symptom control.
Furthermore, they were able to use the electronic medical health record to obtain a palliative care plan and legible scanned living will, stating that her wishes are to avoid hospital admission and care. The family felt peace of mind as their loved one’s goals of care were met. An unwanted, avoidable, and potentially costly conveyance to the emergency department was prevented.
