Paramedics have an increasing role to play in community end-of-life care (EoLC) (Nelson and French, 2012), especially given that the array of symptoms experienced by patients, such as pain, respiratory distress, and confusion, often leads families and carers to call 999 out of fear, lack of control, and inability to cope (Brady, 2013).
Despite the College of Paramedics' Curriculum Guidance (2015) making mention of the need to include palliative and EoLC within paramedic curriculum, specific education remains sporadic—much like out-of-hours specialist EoLC community nursing. This is compounded somewhat by a lack of guidance from the UK Ambulance Services Clinical Practice Guidelines (Association of Ambulance Chief Executives, 2013), which make little specific mention to EoLC.
Ambulance services themselves, however, often have their own policies on the management of palliative and EoLC emergencies, often in line with local referral pathways and commissioning agreements. But given the lack of uniformly national education and guidance on EoLC for paramedics, the publishing of the National Institute for Health and Care Excellence (NICE) guidance: Care of dying adults in the last days of life (NICE, 2015a), is a welcome one.
NICE guidance: Care of dying adults in the last days of life
This guideline, which in part replaces content and the format of the recently disfavoured Liverpool Care Pathway, aims to improve EoLC for people in their last days of life, where paramedics are perhaps more likely to see them. It aims to do this by guiding readers to communicate respectfully with service-users and families, and encourages involving them in decisions about their care, thus increasing the maintenance of comfort and dignity throughout death. This guidance is especially helpful for paramedics in the community, as while it is intended for all healthcare professionals, there is specific aim at those working in a wide range of clinical specialties who do not have specialist level training in EoLC, which Brady (2014) identifies paramedics as.
The guideline covers how to manage common challenges and symptoms, such as:
Recognising when a person may be in the last days of life
Paramedics are skilled in recognising time-critical patients who need access to immediate lifesaving treatment, however, much like many health professionals (including palliativists), they may struggle to predict death trajectory. This guidance sets out signs and symptoms that may be present in those nearing death, such as mottled skin, noisy respiratory secretions, increasing fatigue, loss of appetite, and social withdrawal, and guides the clinician in how best to manage and monitor them in a way that helps determine if death is likely and promotes a good death. This information can guide a paramedic's decision, in line with service-user wishes, to choose the most appropriate care pathway or treatment option, which alongside the other aspects covered within, aim to provide the best death possible.
Communication
Communication is at the heart of good person- and family-centred care, in any interaction, let alone one as emotive as EoLC. Following learning needs analysis and a review of the literature, Pettifer and Bronnert (2013) highlighted a need to include EoLC communication in an educational package designed specifically for paramedics.
This new NICE guidance covers how and when information should be shared or gleaned, and reminds the clinician to consider the person's cultural, religious and social preferences, alongside their mental capacity, and thus ability to communicate and actively participate in their own EoLC. Given that paramedics perhaps normally forgo in-depth personal communication surrounding EoLC, due to their historical aim to preserve life and transport to definitive care, this guidance will assist them in exploring the wishes of the dying person and their family in a step-by-step process.
Share decision-making
Decision making in EoLC has been highlighted by various studies as something which paramedics want and require more education and guidance on (Wiese et al, 2012; Pettifer and Bronnert, 2013). This recent guidance aims to help the clinician establish the level of involvement that the dying person wishes and is able to have, and reminds them of the importance of advance statements or advance decisions to refuse treatment, as well as the need to involve any legal lasting power of attorney. Furthermore, it sets out how shared decision-making contributes to individualised person-centred care, reminding the reader of the practicalities surrounding equipment, resources, and changes to care plans. This guidance is important given that paramedics often have to make significant decisions quickly and in highly charged emotive situations, and aims to help those clinicians who may be less experienced and/or lacking in specific EoLC education, such as paramedics.
Maintaining hydration
While the management of hydration is likely to be an ongoing responsibility of community nurse specialists, and district nursing teams, it is well within the role of paramedics to encourage, where possible and appropriate, the service-user to drink, and to support the family or carers through the individual risks and benefits of keeping the patient hydrated. This guidance covers the clinical assistance of hydration in order to relieve distressing symptoms or signs related to dehydration, which is a complex issue in and of itself, given some of the complications associated with the dying process and any underlying pathologies. It is not known if giving clinically-assisted hydration will prolong life or extend the dying process, just as much as it is unknown if not giving clinically-assisted hydration will hasten death. However, this guidance leads the reader through monitoring hydration, considering the continuation, reduction, or cessation of clinically-assisted hydration, in a way that a non-specialist in EoLC can appreciate.
Pharmacological interventions and anticipatory prescribing
While non-pharmacological interventions are important, and are something paramedics are familiar with in their everyday practice, such as positioning, heat or cold therapy, and compression, pharmacological interventions need to be considered at times. This guidance focuses on non-specialist prescribers, which at the time of writing paramedics are not, but Brady (2014) highlights the benefits of anticipatory prescribing in the form of ‘Just in Case’ boxes for paramedics, in order to alleviate distressing and harmful symptoms; so it is applicable in part to paramedic practice. Anticipatory drugs are prescribed on an individual basis depending on many factors, including any underlying pathology, and are often accompanied by specific indications for use and the dosage required. This new NICE guidance covers the management of pain, breathlessness, nausea and vomiting, anxiety, delirium and agitation, and noisy respiratory secretions, and names drugs which paramedics may indeed find within anticipatory packs or be able to request on script from the patients' own GPs or out-of-hours providers.
Paramedics are permitted and able to administer these anticipatory pre-prescribed drugs, if accompanied by the patient-specific medication chart, signed by an independent prescriber (GP, specialist or nurse independent prescriber), and if they are confident in the administration technique, and the possible side effects, signs of overdose and treatment for overdose, for which there is usually senior clinical support. The use of pharmacological interventions when used in accordance with patients' wishes, shared decision-making, and good communication, in those who it is recognised are nearing the end of their life, often falls to paramedics working both alone and in teams within the community. This guidance can help in their management, especially given the variety of possible pharmacological products available to those for whom we are attempting to achieve the best death possible.
Applicability to paramedic practice
As mentioned within the introduction, given the lack of uniform education and guidance to non-specialist paramedics in the UK, this guideline is a positive step towards the achievement of individual and family EoLC.
It is, however, not without its limitations in applicability to paramedic practice. It focuses very much on ongoing treatment and care within the last days of life, and while paramedic and emergency and unscheduled care professionals were consulted in its writing, they are unlikely to have ongoing involvement in their EoLC—although it is also recognised that more paramedics are working within community teams and not for ambulance services. Paramedics often have to work in highly emotively charged situations with a lack of medical history, family agreement, and information on individual wishes, limiting the applicability of some, but not all, of this NICE guidance, to paramedic practice. Much of this guidance relies on other specialists and other non-specialists, which at the time of use (especially out-of-hours) may not be available, and in some areas may not be available to paramedics.
What is clear, however, is that this well-evidenced guideline, which draws information from multiple national and international sources (NICE, 2015b), provides a succinct but thorough approach for non-specialists to caring for those nearing the end of their lives. When used to support existing knowledge regarding mental capacity, and best interesting decisions, and when used alongside local policy and senior clinical support, paramedics will be guided to be able to plan and often provide high quality EoLC; and this author encourages paramedics to review it, and where possible retain a copy for use in practice.