Paramedic delivery of community-based palliative care: An overlooked resource?

Abstract

Paramedics are increasingly seen as an integral component of health systems in high income countries. This editorial discusses the factors driving the evolution of paramedicine and the role paramedics may play in the delivery of community-based palliative care. The challenges facing paramedics in palliative care contexts are reviewed briefly. Ultimately, this editorial argues that paramedics are important stakeholders in the delivery of community-based palliative care and have been a notable omission in health service policy and planning.

Keywords:

• Ambulance
• Palliative care
• Paramedic
• Paramedicine
• Role

The traditional ambulance service emergency response model has focused on transportation of the sick and injured to hospital. The reinforcement of this view is unsurprising given centuries of historical precedence originating with the first large scale utilisation of ‘brancardiers’ (stretcher bearers) during the Napoleonic wars in the eighteenth century.¹ Indeed, transportation continued to be the principal service delivery paradigm underpinning many ambulance services through to the 1970's.² In recent times, however, the profession of paramedicine has been evolving rapidly.

The evolution of paramedicine is driven by numerous factors including the increased use of emergency department and hospital services by an ageing population,^3–5 the underservicing of healthcare to communities particularly in regional areas,⁶ the prevalence of chronic diseases,⁷ health workforce shortages,⁸ and the continued professionalisation of paramedics.⁹ Arguably, professionalisation is one of the more significant drivers of change and can be evidenced in part by a shift in paramedic education in the UK and Australasian ambulance jurisdictions from an in-house vocational model to a pre-employment university-based training model.¹⁰ Furthermore, paramedics are specialising in roles beyond the traditional emergency response model such as community paramedicine.¹¹ These factors, inter alia, have prompted the increased utilisation of paramedics in the delivery of community-based services including palliative and end-of-life care.

Ambulance services globally are progressively embracing new paradigms of care, including palliative care, with the view of improved holistic support for patients at home.^12,13 In Australia for instance, NSW Ambulance has engaged collaboratively with other health services to develop palliative care plans that inform the attending paramedic of resuscitation plans, treatment for specific symptoms (including out-of-paramedic scope), guidance for where the patient may be admitted, if required, and contact details of other services involved in the patient's care.¹⁴ Additionally, paramedics are already well placed as a mobile healthcare workforce to respond to patients requiring unscheduled care. Within Australian jurisdictions in 2017–18 for instance, 14 467 salaried paramedics responded from over a thousand locations to make contact with 3.5 million patients.¹⁵

However, the utilisation of paramedics within palliative care contexts is not without challenges. In Canada, for example, despite the high proportions of patients expressing a preference to die at home, over half of patients requiring palliative care who contacted an ambulance were transported to an emergency department, hospital or hospice facility.¹² More recently, higher transport rates have been reported in Australia with approximately three-quarters of the 4348 palliative care patients who contacted a state ambulance service in a 12 month period were transported.¹⁶ Caring for patients receiving palliative care may seem contrary to the traditional life-saving focus of paramedic practice, although paramedics appear to have a sound understanding of important aspects of palliative care with respect to symptom control and holistic care.¹⁷ The core of the issue may lie in a lack of confidence and competence in managing palliative patients due to a perceived aperture in paramedic education.¹²

Despite the ongoing perceptual challenges across health systems in understanding what paramedics ‘do’, it is curious to note that paramedics and ambulance services are not referenced at state¹⁸ and national-level¹⁹ peak palliative care review and policy documents in Australia. This omission is despite paramedicine recently becoming the 15th registered health profession in Australia, after their UK counterparts first registered some two decades ago. It is clear that further research is required to better understand the sociological, operational and educative issues in optimising paramedic delivery of palliative care.

However, paramedics have been delivering palliative care in numerous jurisdictions globally for some time with promising outcomes.^12,20 Yet despite recognition of the need for collaborative engagement across multiple service providers to achieve high-quality patient-centred palliative care, ambulance paramedics have notably been missing from the table.

ORCID

David Long http://orcid.org/0000-0002-6278-7377