There is a growth of interest in paramedic involvement in end-of-life care issues in general, but one sub-group of the population which clearly requires further investigation relates to people residing in nursing homes. It is known that frequently people in nursing homes, who are nearing the end of their lives, are inappropriately transferred to hospital with potentially negative consequences.
Little is known about paramedics' clinical decision-making in end-of-life care situations involving these patients, so this study makes a valuable contribution by exploring what factors influence paramedics' clinical decisions when asked to transport nursing home residents nearing the end of their lives.
Utilising a phenomenological approach, a total of six paramedics participated in semi-structured interviews. Participants included three female and three male paramedics aged between 24 and 42 years, and their length of service varied between 2–8 years.
The interviews were structured round six core questions (usefully included in the online supplementary appendices) plus photo elicitation using two images depicting both the context and the type of patient providing the focus for this study. The interviews were audio-recorded and subsequently transcribed verbatim prior to analysis.
In addition, participants were invited to text the researcher about their experiences and thoughts after attending these patients and these data were analysed alongside the interviews using thematic analysis.
Ultimately three themes emerged: the challenges in understanding patients' wishes; evaluating patients' best interests; and the influences of others on decision making.
Paramedics wanted to be able to understand patients' wishes but, all too frequently, it was felt that the documentation of advanced care plans was lacking or, indeed, absent. If patients' wishes were documented this focused, in the main, on Do Not Attempt Resuscitation orders.
If patients did not have capacity, participants reported using factors such as co-morbidities, diagnoses, reported quality of life, current condition and any documented statement of individuals' preferences to evaluate the patients' best interests. It was noted that some of the paramedics were unable to specifically articulate how these processes occurred but, in the end, they weighed up the balance of perceived risks and benefits of hospitalisation to the individual patients.
Other people including nursing home staff, patients' relatives, as well as other paramedics, clearly influenced the decision-making process. Some participants felt that nursing home staff sometimes appeared unable to cope with an individual who was dying. Other participants reported challenges in managing relatives especially if the relatives' views about transfer to hospital appear to be in conflict with the patients. Overall, uncertainty in decision-making was evident, which is unsurprising given the challenges that paramedics frequently encounter in establishing the patient's wishes especially if the patient is unable to communicate, their wishes have not been clearly documented, and/or the nursing home staff are uninformed.
The authors identify limitations of the study including a small sample size, taken from one ambulance service. However, at no time do the authors attempt to generalise their findings as this would be an inappropriate use of qualitative research. This is a well-written paper which starts to address some of the considerations in this area of paramedic practice.
They conclude that a wide range of factors impact on paramedics' decisions as to whether or not to transfer patients to the emergency department at this end stage of the patient's life. Further research is required to ascertain what additional education and support is needed to better prepare healthcare professionals to manage these challenging and, frequently, complex situations.