Paramedics could fill gap in palliative care: research

More patients approaching their end of life could die comfortably at home if paramedics were better equipped to help them, according to new research.

The research, Paramedics delivering palliative and end-of-life care in community-based settings: A systematic integrative review with thematic synthesis, found opportunities for paramedics to fill gaps in palliative care.

Funded by HammondCare, the research was a literature review of previous studies and is part of a broader PhD project.

Madeleine Juhrmann, research author and PhD candidate at the University of Sydney Northern Clinical School, said that paramedics could help fill this gap by providing an adjunct service.

“I think it’s most important to emphasise that paramedics should not be replacing or taking over from existing community-based palliative care services,” she told Community Care Review.

“Paramedics are a generalist workforce; they do not provide specialist care and there will always be a time and place for that that scope of practice.”

Based on the qualitative interviews she’s recently conducted and the policy study she’s undertaken, she believes the ideal situation would be for a paramedic to go into the home of a palliative patient and respond to their symptoms of distress.

“If the paramedic had a clinical guideline, that would allow them to be able to alleviate that pain… and to be able to treat the patient but then refer them to a community palliative care service,” Ms Juhrmann said.

Existing barriers

However, there are certain barriers preventing paramedics from providing this type of support, including limited access or untimely access to documented wishes, such as an advance care directive or an advance care plan.

Family discordance was another problem, where families don’t share the same goals for the patient, with some family members preferring palliative care and others preferring them to go to hospital.

The medical legal ambiguity surrounding palliative care is also a concern for paramedics, who are fearful of litigation if they treat the patient and don’t transfer them to hospital.

This comes back to their traditional role as “conveyors to hospital”, according to Ms Juhrmann.

Overcoming barriers

A possible solution to this could be strengthening communication and support channels with multidisciplinary teams, she said.

“If paramedics have the ability to be able to call and seek clinical support or backup when they are treating a palliative patient… then they’re far more likely to be able to facilitate home-based deaths or keep the patient at home if that’s their preference,” Ms Juhrmann said.

Targeted palliative care training for paramedics would also be helpful, she said, along with partnering with families.

“If paramedics have the skills and expertise to be able to engage the families…from the beginning, establish rapport and be part of shared decision making, the likelihood of the patient’s goals being facilitated and them being able to live and die at home is far more likely.”

Palliative care specific clinical practice guidelines would also be helpful, she said, such as allowing paramedics to provide opioids for pain management and relief and to engage with non-pharmaceutical approaches to symptom management.

The guidelines could also provide general guidance on how to identify and respond to the death and deterioration of a palliative patient.

Ambulance services in Australia

Currently, five out of eight jurisdictions in Australia have existing clinical practice guidelines on palliative and end-of-life care for ambulance services, according to Ms Juhrmann.

These include NSW, Victoria Queensland, South Australia and the Northern Territory.

“I think that Australian ambulance services are making significant strides in improving and broadening their current scope of practice to deliver palliative and end-of-life care and community,” she said.  

“I think that in the coming years we are already seeing a significant change in the way that paramedics are able to approach palliative patients and feel empowered to take a palliative approach to care.”

Further research

The next part of Ms Juhrmann’s research will be conducting qualitative interviews with paramedics, GPs, palliative care doctors, and nurses and other health professionals, on the role of paramedics providing palliative and end-of-life care in their communities.

She has already conducted a comparative policy analysis that looked at the existing clinical practice guidelines within Australia in comparison to international health systems and ambulance services.

“Palliative paramedicine is an emerging scope of practice and community-based ambulance services are a widely unharnessed asset,” Ms Juhrmann said.

Her and her team are currently recruiting families and carers with lived experience of palliative paramedicine, along with residential aged care managers, GPs and palliative care doctors and nurses.

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