Hospice in the Weald began hiring paramedics in autumn of 2018 to meet the community's pressing hospice palliative care needs. As a result, paramedics have had their role extended to hospice settings and have become specialist palliative care providers for our end-of-life care patients. Employing hospice paramedics helps boost our clinical staff numbers to meet the growing needs of an ageing population.
Paramedics work across all of our clinical services, including hospice outreach, cottage hospice and inpatient ward. Currently, we have 12 paramedics working across these services, five of which are bank staff. This article presents the on-the-job role and experiences of two paramedics who are working in our hospice outreach service.
Vicki Fuller has worked with the hospice for 3 years, first as a paramedic and now as a clinical paramedic specialist. Vicki provides insight into how she came to working in a hospice:
‘I began my career in paramedicine as an ambulance paramedic. I did not enjoy the unsocial hours of ambulance paramedicine, so I made a change and started working as an accident and emergency (A&E) hospital paramedic liaison officer. This was a novel role for paramedics that gave me experience in acute care. This gave me the confidence to take advantage of another opportunity that came my way: being a community paramedic tasked with reducing hospital admissions. While working as a community paramedic, I developed my experience in palliative care and enjoyed it very much. I decided to specialise in palliative care when this job post opened at the hospice in 2018.
Hospice in the Weald was the first hospice to employ paramedics and I was among the first cohort of hospice paramedics and clinical paramedic specialists recruited. I already had a wide portfolio of skills and experience which helped with my transition into the hospice. Other paramedics in my cohort found it much more of a challenge. It was much more of a difficult shift for others than it was for me.’
For Luke Thomson, joining Hospice in the Weald was motivated by two factors: ‘First, I wanted to challenge myself and learn more. Second, the hospice provided the opportunity to be in a clearly defined role where I can provide patients a respectful, dignified and pain-free care at the end of life with access to other services to support.’
Luke completed a paramedic science foundation course at Coventry University in 2012. He qualified as a paramedic and worked for South East Coast Ambulance Service (SECAMB) in Paddock Wood. After almost 10 years in the ambulance service, he decided he was ready for a new challenge. He has been working at the hospice for 3 months.
Prior to this role, he had no specific training in end-of-life and hospice care, but he notes that there are those occasional moments in ambulance work where one comes into contact with hospice palliative care patients. ‘This was usually hospice patients who turn to 999 during the out of hours setting,’ Luke explains, ‘In an ideal world, with hospice care, patients should not need to dial 999. A good sign that the hospice is effective is that you rarely come across hospice patients in the ambulance, which was the case.’
Both Vicki and Luke agree that there is a change in mindset for this job from saving people, to making people more comfortable and dignified at the end of their life.
Time and how it is spent is a valued component of working as a paramedic in hospice palliative care. ‘Time management is the biggest part of the job,’ Luke explains, ‘There is a lot of self-management and direction needed to ensure that you can get through the diary.’ The diary includes three to four patient visits in their place of residence and follow-up calls to patients under the Hospices' care. All of this is done from 8:00 am to 6:00 pm. Luke explains: ‘At 8:00 am, there is a team meeting for the area you cover. I am part of a team that covers Weald and East Sussex. I meet with other staff members (like clinical nurse specialists, nursing assistants, paramedics) and we go through our diary. We visualise where everyone is and consolidate visits to reduce the travel time between patients. So, for example, if I am visiting a patient in Weald and Vicki has a patient in Weald, I can do both visits to avoid a longer commute for Vicki.’
They also discuss challenges and provide support to each other regarding the task ahead.
Following the meeting, the paramedics make calls ahead to the patients to inform them of their visit. If anything has changed (for example, if a patient has passed away, is not available or no longer in need of a visit), this can be reflected in their plans before they set off on the road. If patients would also like the visit delayed by a few hours, or moved to another day, the paramedics can prioritise other tasks such as follow-up calls to other patients, clinicians, or GPs. There is a fair amount of flexibility in how the day proceeds.
Luke explains: ‘You rank the calls and determine when the visits should happen. As tasks come in, some need to be prioritised. For example, during an initial patient assessment, a lot of documentation is needed, some of which has to be shared with other services or the wider healthcare network. You need to always consider what time you can visit and, generally, between 9:00 am and 4:00 pm, things can get done quickly. The situation might be dire, and the patient is in urgent need of things so prioritising those visits and initial assessment is crucial.’
Vicki provides further insight: ‘Meetings with patients can take longer than intended as you don't really know what you will see when you walk in. Patients can be acutely unwell or require assistance with personal care. The patient might have difficulty communicating and it can take time to build up a relationship with the patient and their family. You have to be willing to spend the time to build the rapport.’
Vicki notes that a typical visit with a patient involves assessing the patient illness trajectory. ‘A crucial part of this is ascertaining if they are in the dying phase or not. If they are, the next step is determining if they will be better supported with a hospice admission or further support in the home.’
She communicates her assessments and recommendations to the patient and his or her loved ones. She uses direct language when communicating where the patient is along their care journey and ensures there is mutual understanding of what is needed. Vicki also emphasised the importance of gaining family support as they play such an integral role in the patient's end of life care experience. Part of their role involves identifying deteriorating patients and complex patients that need to be escalated to a more senior clinician, such as a doctor, advanced nurse practitioner, clinical nurse specialist or a clinical paramedic specialist.
Both Vicki and Luke emphasise that there is specialist knowledge needed in their role and this takes time to develop. ‘When I began, the clinical paramedic specialist role was not a nationally recognised position,’ Vicki explains, ‘but it is now. When I wanted to progress to a clinical paramedic specialist, I was supported. Hospice in the Weald prefers to train and promote its own staff so they sponsored me to do master's level modules in palliative care at a university to facilitate this progression. The clinical paramedic specialist is at the same level and responsibility as a clinical nurse specialist with a team of juniors below. Working as a paramedic in a hospice is a different way of working but I am glad that I had the community experience before coming to the hospice.’
While certain skills such as cannulation and intubation are not relevant to the day-to-day role, it is important to acknowledge that there are transferable skills and underpinning knowledge that paramedics bring into their role. ‘We are used to working autonomously,’ Vicki explains. ‘We as paramedics are more adaptable and very used to walking into a situation with limited information.’ Luke agrees, ‘We are used to solving problems really quickly. We as paramedics can now apply quick decision-making with limited information into the hospice context, allowing our patients a comfortable and dignified experience at the end of life.’
Both Vicki and Luke highlight their adaptable communication skills as an asset, particularly within the wider healthcare network. In communicating with the patient, their ability to compartmentalise their patient assessment from the patient record allows them to be responsive to the patient's present needs.
‘You have to learn to gather information quickly. At the hospice, we have patient records that include notes from the hospice staff, GPs and hospital team. However, as a paramedic, you learn to find out from the point of view of the patient what is happening. You learn to set that [records] aside for a moment when doing the assessment to really answer the question of “why am I here?” We then bring together what the patient is telling us and what the records are telling us to really understand what is happening.’
In hospice palliative care, you have the chance to follow up with the patients, request input from other specialists within the hospice such as counsellors, physical therapists or occupational therapists, or other forms of support such as a commode or hospital bed.
‘A commode or a handlebar in the shower can really change someone's life, especially in the last few weeks of life,’ Luke explains.
In this role, there is substantial upskilling of the paramedics in palliative and end of life care skills which includes pain management and symptom control. Vicki notes that she has achieved a lot but acknowledges there is more learning to be had: ‘I've developed new skills, particularly getting more comfortable with end-of-life care medications as well as how to manage and cope with end-of-life care symptoms in patients.’ Luke agrees: ‘Working as a hospice paramedic is a much more specific role. You are tasked with providing the best end-of-life care possible while working with the hospice team and the wider healthcare team.
The hospice is a great place for a paramedic to work as it integrates a lot of the care delivered from other sectors. Hospices are in the middle; we are seen as a resource by these teams, and we see all of these teams as a resource. Hospices bring solutions to these teams, helping GP practices to effectively care for their dying patients.’