Widening the conversation: Paramedic involvement in interprofessional care

In this special issue of Progress in Palliative Care we explore the nexus between palliative care and paramedicine by presenting important initiatives being undertaken in Australia, New Zealand, the United Kingdom, and Canada to improve access to care. In each of the settings described, paramedics are regulated or registered health care professionals working in health settings that include ambulance or emergency medical services. Paramedics within these regions can be rapidly deployed to provide urgent health care to the entire population of the areas they serve, including areas that are not served by out of hours specialist palliative care.

We know that paramedics are involved in care for patients who may be experiencing a health crisis related to a life-limiting condition, and that the call to the emergency service may arise from distressing symptoms such as pain, agitation, respiratory distress, and nausea. Although paramedics can provide symptom relief, paramedic practice has traditionally focussed on the assessment and management of acute injury and illness rather than chronic illness and the care of patients and their carers, particularly at end of life. Previous research found that paramedics perceived that limited exposure to palliative education, lack of practice guidelines that address the needs of palliative care patients, and limited referral options and 24-hour access to specialist advice inhibit their ability to provide safe and effective care for patients in their home, particularly at the end of life. ¹ In countries such as Australia, these barriers to care in the community result in most calls relating to a palliative crisis being transferred by ambulance to an emergency department. ²

The contributions to this special issue describe initiatives that involve paramedics and ambulance services planning for care that may include a broader range of management options than the default option of transport to a hospital. It is recognised that patients may experience illness or injury that is unrelated to their palliative condition, and that health emergencies associated with a life-limiting illness may require hospital admission. However, where the patient expresses a preference for care at home or has an advance care directive that describes this preference, every opportunity should be explored to pursue the universal maxim of person-centred care.

In order to achieve this Carter and colleagues³ present the outcome of a national collaborative initiative in Canada that aims to support paramedics in the provision of care in the home, and develop mechanisms to share patient goals of care with other members of the multi-disciplinary healthcare team to ensure that the patient’s wishes are respected.

Murphy-Jones and colleagues⁴ describe two case reports of UK ambulance service improvement programmes that involved collaboration with a specialist palliative care service to support paramedics and identify appropriate alternatives to hospital conveyance. They discuss the need to educate paramedics in palliative care and examine the development of specialist paramedic roles in end-of-life care.

Care pathways are the focus of a report by Helmer and colleagues,⁵ who describe the development of a new clinical pathway that aims to improve patient-oriented care by enabling paramedics to provide care for patients in their own home, potentially reducing the requirement for transfer to an emergency department.

Conversations about the need for advance care directives are often difficult to initiate, and as such, Goodwin et al.⁶ sought to identify paramedics’ views on their involvement in proactive identification of patients in their final stage of life and the initiation of conversations regarding advance care planning in the United Kingdom.

Both Anderson⁷ and Cameron,⁸ together with their colleagues, remind us that paramedics are often present at the time of death of a patient and that support of carers and family members at this time is a vital professional responsibility, yet paramedics may not be well supported or prepared for this role. This may include decisions to withhold or withdraw resuscitation. These reports recommend engagement with interprofessional colleagues in palliative, grief, and bereavement care to develop strategies to enable conversations about dying and the care of the dying and the bereaved.

Pekarsky et al.⁹ found that although paramedics are involved in the assessment and treatment of individuals receiving palliative care in Australia, there is little evidence of paramedic inclusion in local and national strategies for palliative care. This suggests that there is a need to advocate for paramedic and ambulance service involvement in strategic planning for the delivery of palliative care based on the outcomes described in this special issue.

Finally, an innovative specialist palliative care telehealth service for use by paramedics is discussed by James and colleagues,¹⁰ with a particular focus on the attitudes of paramedics using the service. Through an improved understanding of paramedic attitudes, planners are better able to design and deliver telepalliative care services with a higher degree of confidence in improving outcomes for people with life-limiting illness and their families.

While a small proportion of highly experienced paramedics such as Extended Care Paramedics¹¹ and Community Paramedics¹² have received specialised training in palliative care for some time, there is a clear need to prepare the wider paramedic community for the care of patients with palliative care needs. This groundwork must involve interprofessional inclusion in the design and delivery of palliative care education in entry-to-practice programmes. Furthermore, despite clear evidence of need, palliative care is not commonly referenced in professional competencies, including the recently published ‘Professional capabilities for registered paramedics’ in Australia.¹³ Other barriers to paramedic involvement in palliative care include funding issues, as palliative care may not be seen as a component of the service delivery model for ambulance services who have broad responsibilities for patient retrieval, management of acute health emergencies and responses to major incidents and emergencies including natural disasters. Involvement of paramedics in care for patients receiving palliative care in the community will typically require longer time spent with the patient and their carers, and this may be inconsistent with current workflow needs that demand rapid scene assessment and transport where indicated to maintain the responsiveness of ambulance services.

The next steps should involve assessment of the caseload and nature of the care currently being provided by paramedics to palliative care patients in the community to better understand local needs, particularly in rural and remote areas. Ambulance services and professional associations should join with local and national palliative care advocates to investigate opportunities for improvement where this has been identified, and work collaboratively with health professions with responsibilities for palliative care to investigate ways of ensuring that paramedics are able to provide appropriate care when and where required.