Paramedics in England are experiencing wide-ranging challenges in responding to the increasing number of end-of-life care patients they are being called out to, according to a study from the University of Southampton.
The study published in BMC Palliative Care highlights the issues paramedics face when responding to patients at end-of-life, including a lack of patient information, barriers to administering medication, and insufficient training.
It was funded by Marie Curie and supported by National Institute for Health and Care Research (NIHR) Applied Research Collaboration Wessex.
An ageing population coupled with shortfalls in community healthcare services is placing an increasing reliance on paramedics to deliver care during a patient's last year of life.
Dr Natasha Campling , Associate Professor at the University of Southampton and lead author of the paper says: "Often ambulance paramedics respond to acute conditions via 999 calls where their role is to preserve life, treating patients quickly on scene to stabilise them so they can then be transferred to hospital.
"For patients at end of life, when paramedics are called to scene they need to be able to, for example, distinguish between reversible causes that require hospital treatment and those associated with underlying condition(s) or the dying process that can be relieved through palliative care and appropriate symptom management.
"Our research shows that paramedics are being asked to make such complex decisions without all of the necessary information, support, resources and training to do so."
Researchers at the University of Southampton conducted an online survey of over 900 paramedics across all 11 NHS trusts employing paramedics in England to understand their experience of delivering this kind of care.
Paramedics frequently attend patients in their last year of life, with 57 per cent estimating that they do so at least every seven shifts, and 89 per cent at least every 14 shifts.
But prior to arrival, 45 per cent of paramedics reported never or rarely knowing the patient's end-of-life status – just 14 per cent said they often or always knew.
Paramedics regularly lacked access to crucial information, such as patient medical history and advance care planning documents, which state preferences and wishes for care. Frequently, prior discussions around advance care planning had not happened at all.
As such, over half of paramedics often or always encountered conflicting views on how best to care for the patient, for example between the crew, family members and the GP. Paramedics found it difficult to challenge another healthcare professional's recommendation that the patient be taken to hospital if they didn't think this was the right course of action.
Furthermore, advice from, and referral to other healthcare professionals or teams was problematic, particularly out-of-hours and to community nursing and specialist palliative care teams.
Dr Sarah Holmes, Chief Medical Officer at Marie Curie, said: "We know that pressures on ambulance services are significant, and this study highlights the importance of equipping paramedics with the right tools to do their work.
"Life preservation is their primary role, but this study shows they will also often be faced with palliative care scenarios, too. It is vital that we take the wishes of those at the end of life to heart where at all possible and put robust plans in place to help health care professionals do their jobs, at every step of the process."
Nearly three-quarters of paramedics reported sometimes or often not having access to specific anticipatory medicines needed to relieve symptoms at end of life. Most ambulance crews don't carry these so called 'just in case' drugs, so they more often come from a patient's own supplies.
However, authorisation to administer the patient's drugs is dependent on a Medicines Authorisation and Administration Record (MAAR), which paramedics frequently had problems accessing.
Paramedics also highlighted a lack of pre-registration training in end-of-life care and insufficient continuing professional development in this area.
"Taken together, these challenges have left many paramedics fearful of making the wrong decisions and lacking full confidence in their ability to care for and meet the needs of patients at end of life," says Professor Sue Latter from the University of Southampton, a co-author on the paper.
The researchers make several recommendations for service improvement, focusing on end-of-life training and education; access to records and documentation; access to referral pathways including 24/7 palliative care advice; and anticipatory medications carried by crews with the authority to administer them.
On improving access to medications, Professor Latter added: "Realistically, it's likely that paramedics will continue to play an important role in end-of-life care provision and therefore finding effective ways for them to access, supply and administer crucial medicines to end-of-life patients in order to avoid unnecessary conveyance to hospital needs full consideration and evaluation."
Paramedics providing end-of-life care: an online survey of practice and experiences is published in BMC Palliative Care and is available online.
