Enhanced Palliative Care: A Guide for Paramedics, Nurses and Doctors was edited by Neil Pryde and was published in 2021 by Class Professional Publishing. This book has almost 100 collaborators from nursing, medicine, paramedicine, social work, pastoral care and specialist educators.
It was designed as a training manual to support clinicians providing palliative care to patients at or near the end of their life. According to the World Health Organization (2020):
‘Palliative care is an approach that improves the quality of life of patients (adults and children) and their families who are facing problems associated with a life-threatening illness. It prevents and relieves suffering through the early identification, correct assessment and treatment of pain and other problems, whether physical, psychosocial or spiritual’.
This allows for a multidisciplinary approach to supporting patients. This book helps address the essential overlapping care models and create a unified approach to caring for patients. With its foundations in the Scottish Palliative Care Guidelines, this book is cover-to-cover evidence-based teaching, backed by one of the largest cancer charities in the UK, Macmillan Cancer Support.
It is quite well documented that many paramedics receive little education on end-of-life care and bereavement, but are a uniquely well-positioned group to support patients in need of or already receiving palliative care. While there are bigger issues around paramedic education and palliative care that need to be addressed, this book is an invaluable resource for anyone with an interest in palliative care or those providing care.
Background
Chapter 1 describes the background and development of the medical specialty of palliative medicine, the importance of dying with dignity and the positive impact of advanced care planning. It also discusses the beneficial impact of a multidisciplinary team approach to caring for patients at the end of life.
Ethics
Chapter 2 covers the fundamentally important ethical and medico-legal issues surrounding end-of-life care. Although I am a paramedic in Ireland and there are going to be differences in legislation, the chapter is very informative on the subjects of do-not-attempt cardiopulmonary resuscitation (DNACPR) orders, capacity, advanced directives and power of attorney. In Ireland, The Assisted Decision-Making (Capacity) Act 2015 was signed into law (in Ireland) to support decision-making by adults who have difficulty making decisions without help. While this legislation is establishing new support services for people to make decisions regarding their care, this has had a significant impact on existing DNACPR orders and is something that paramedics in Ireland should be aware of (Department of Justice, 2015).
Communication
Chapter 3 is focused on communication including:
Each chapter has scenarios featuring different patients at different stages of treatment, along with the impact of ‘good’ and ‘bad’ communication. The topics of sharing bad news, shared decision-making and capacity could be very useful for paramedics who want to work on those inevitable ‘breaking bad news’ conversations that we will all encounter on calls.
Symptoms
Chapter 4 is the most extensive chapter covering a variety of symptoms and how to manage these symptoms to ensure that patient comfort is of utmost importance. Topics include pain management, nausea and vomiting, constipation, diarrhoea, breathlessness, cough, anxiety, delirium, agitation, and fatigue.
Medication
Chapter 5 is dedicated to drugs and medication. This chapter was interesting to me as I am very particular in establishing a comprehensive patient and medication history on calls I attend. I learned a valuable lesson in my early intern paramedic practice about the importance of finding out the medication schedule for oncology patients if they end up needing to attend the emergency department for any reason. Paramedics are one of the few medical professionals that see people in their home environment and may be able to detect issues with medication management. This can be vital to ensure the best medication administration options are made available to patients.
End-stage disease
Chapter 6 discusses the following medical conditions in depth: end-stage heart failure, end-stage respiratory disease, motor neuron disease, diabetes, end-stage liver disease and kidney failure. By the end of the chapter, the reader should be able to recognise and manage these conditions. I found this chapter useful as it provides a succinct overview of the conditions and a great refresher of their pathophysiology.
Psychosocial and spiritual
Chapter 7 explores the psychosocial and spiritual aspects of palliative and end-of-life care. Death and faith are uniquely intertwined, and while caring for those at the end of life may mean many (or few) medical interventions, it is crucially important that the spiritual and faith-based needs of the patient and their family are upheld and incorporated into a holistic care plan. In 5 or 10 years, I may not remember a particular patient, but the family will very likely remember the ambulance crews and other medical professionals involved in the care of their loved one; this goes to show the importance of being aware of and respecting people's spiritual needs.
Emergencies
Chapter 8 focuses on six palliative care emergencies that are truly time-sensitive. The scenarios presented show the importance of recognition and timely management of these conditions and the negative outcomes if not treated quickly. Each disease morphology is covered by an introduction to the condition, assessment and examination of the patient, typical symptoms, key management and then a scenario recap. The conditions discussed are hypercalcemia of malignancy, malignant spinal cord compression, bleeding, seizures, superior vena cava compression, and bowel obstruction.
Rehabilitation
Chapters 9, 10 and 11 cover the subjects of rehabilitation and the benefits to patients at the end of their lives, complementary therapies such as meditation, mindfulness, reflexology, aromatherapy, reiki and hypnotherapy. While many medics may completely disregard these therapies as dubious and not based on science, these therapies all have a place and, in particular, for those at the end of their lives, where medical interventions may have more negative side effects than positive impacts. Whatever medics' personal views are on complementary therapies, we must show respect for patients' wishes and not be dismissive of these therapies.
Specialist needs
Chapter 12 is particularly important as it discusses palliative care in specific populations including the needs for LGBTQ+ patients, patients with learning disabilities, remote and rural populations, people experiencing homelessness, people living in poverty and people in prison. I am particularly interested in providing care to indigenous communities; people within the Irish Traveller community have very specific rituals and practices for the care of their loved ones around and at the time of death. I would like it if there was information in this book on supporting the Traveller community in the context of palliative and end-of-life care.
Holistic management
Chapters, chapters 13 and 14, of the book discuss the complexities of recognising the dying patient and the importance of a holistic care management plan and how to manage a dying patient in a variety of care settings. The final topic of the book covers grief, the different types of grief and understanding of the principles of bereavement care. For paramedics who are interested in more resources related to grief, I have found the online portal, The Canadian Virtual Hospice-My Grief Toolbox, to be very useful. These are a series of online modules designed by paramedics and grief specialists. They provide support and personalised information about advanced illness, palliative care, and loss and grief, to people living with illness, family members, people working in healthcare, as well as educators, and researchers (Canadian Virtual Hospice, 2022).
In summary
This textbook is probably the most thought-provoking and comprehensive textbook I have ever read and I am very thankful for having the opportunity to read and review it. While we do not yet have paramedics in Ireland who have specialised in providing palliative care, such as those working across the UK, I feel that this book will be beneficial to anyone who is already providing end-of-life care or someone simply interested in the subject.