With the population ageing, paramedics are increasingly attending palliative and end-of-life (EOL) patients in the community. Patients and families often call 999 in times of distress when they are unable to contact the patient's palliative care team or general practice (Murphy-Jones et al, 2021).
Palliative care services vary considerably across the UK. Cox et al (2016) found in their review of London palliative care services that only 9 of the 30 hospital palliative care teams and 17 of the 26 community palliative care teams were available 7 days a week. Not only are many services not available 7 days a week, the majority do not even operate 24 hours a day.
Williams et al (2019) identified 695 safety incidents involving adverse outcomes for palliative patients cared for by out-of-hours services over a period of 4 years and 10 months, and found 199 of these incidents related to delayed access to medication. These authors recognised that this figure likely underrepresents adverse outcomes of palliative patients owing to the subjective nature of identifying harm.
The Joint Royal Colleges Ambulance Liaison Committee (JRCALC) EOL care protocol recommends ambulance clinicians share decision-making with other health professionals, such as GPs or care teams (Association of Ambulance Chief Executives (AACE), 2019).
The funding model for palliative care services in the UK is heavily reliant on charitable funding, with only 30% of income sourced from the government and the NHS (Jackson, 2022). Hospice UK (2023) recently reported that hospices in England have had a £47 million pay cut over 2 years owing to inflation without an increase in funding. As a result, palliative care services are unable to service the community 24 hours a day and it appears patients are therefore experiencing adverse health outcomes. An analysis by Marie Curie (2023) predicts that by 2048, patients requiring palliative care support in the UK will increase by 147 000 as a direct result of the ageing population, and will greatly overwhelm palliative care services.
This review will explore the role of paramedics in end-of-life care in the community by considering existing practice in the NHS and identifying requirements to improve practice.
Importance of symptom management in end-of-life care
Ineffective symptom control is one of the most influential factors for a palliative patient, their family or caregivers to call 999 (Blackmore, 2022).
Star and Boland (2018) highlighted the most common symptoms at EOL, notably pain, nausea and vomiting, breathlessness, delirium, opioid-induced constipation and upper respiratory tract secretions. They stress the importance of careful assessment and the trial and consideration of non-pharmacological treatments, both before and in combination with pharmacological therapies.
However, in a community setting, this can be time consuming and not always practical. An evaluation of 284 inpatients unknown to palliative care services in 88 UK hospitals by Tavabie et al (2023) found that 93% of this cohort had unmet needs, with 75% of these involving distressing physical symptoms. While this study highlighted the lack of symptom control for patients dying in hospital, it did not identify why these symptoms remained uncontrolled nor why these patients were unknown to hospital palliative care teams. If the rate of symptom control is insufficient in hospitals where patients have direct access to health professionals, it is reasonable to infer that this rate is significantly higher for patients in the community, contributing to an increasing reliance on emergency paramedics.
Gerber et al (2021) suggested a lack of knowledge and experience were contributing factors to inadequate symptom management, based on interviews of Australian nurses; however, these research findings may not be transferable to paramedic experience of practice in the UK. Similarly, the findings in the UK study by Kirk et al (2017) looking at the perceptions and confidence levels of paramedics in EOL care, highlighted the necessity of specific education to ensure competence and skilled care.
Additionally, a literature review undertaken by Pentaris et al (2019) in the UK examining paramedics' attitudes and perceptions of EOL care similarly suggested education and training are required to address skills and confidence levels needed for complex EOL care. However, a limitation noted in this review is the lack of UK studies it included. These researchers stressed that further research in the UK in this area of practice was needed.
Paramedics within the UK adhere to the JRCALC (AACE, 2019) guidelines to direct clinical practice. The guidelines are created by an independent committee of multidisciplinary health professionals, and specific protocols are developed by specialist sub-groups (Smith, 2023). JRCALC does not disclose the members of the sub-group who were consulted on the EOL care guideline, so the knowledge base can be analysed only by the listed references. The committee itself contains no specialist palliative care professionals and the EOL guideline is based on research dated between 1979 and 2017 (AACE, 2019).
Clinical practice guidelines can be an invaluable resource for health professionals, especially those with limited clinical experience, to guide safe decision-making (Ebben, et al, 2013; Harris, et al, 2021). However, in the authors' opinion, the JRCALC EOL care guideline reflects the apparent lack of existing literature and evidence to support EOL practice in the community.
On examining the JRCALC EOL care guideline (AACE, 2019), it was identified that paramedics are unable to provide adequate symptom management as they are unable to prescribe anticipatory medication.
One example is the management of delirium and agitation in dying patients, a common symptom at EOL requiring urgent assessment and care, for which JRCALC (AACE, 2019) and the National Institute for Health and Care Excellence (NICE) (2023) have similar recommendations. JRCALC suggests managing agitation with both pharmacological and non-pharmacological strategies and NICE guidance recommends clinicians consider administering low doses of haloperidol if de-escalation techniques are unsuccessful (AACE, 2019; NICE, 2023).
NICE (2015) conducted a literature review to identify which benzodiazepines and antipsychotics are most effective in treating agitation in EOL patients. The review concluded that no such evidence existed and, as a result, clinicians are hesitant to administer sedative medication owing to fears of over-sedating dying patients (NICE, 2015). JRCALC suggests using patients' own anticipatory medication to reduce agitation (AACE, 2019).
It is not within the JRCALC paramedic scope of practice to prescribe antipsychotic or sedative medication for the management of delirium. However, advanced paramedic practitioners in urgent care are authorised to administer midazolam for agitation to EOL patients who have not already been prescribed anticipatory medication (AACE, 2019). There are a maximum of 14 advanced paramedic practitioners in urgent care available to respond to patients in the community, pan London, per day (as confirmed via email correspondence between the lead author and A Hichisson on 24 May 2025). These advanced practitioners cover a large geographic area and may be more likely to be delayed in responding to patients at EOL than their paramedic colleagues. Therefore, if a dying patient has not been pre-emptively prescribed anticipatory medication, it may pose a significant barrier in controlling their distressing symptoms.
In response to the COVID-19 pandemic, the Welsh Ambulance Service began carrying anticipatory medication on emergency ambulances (O'Brian et al, 2023). This initiative continued beyond the pandemic, and O'Brian et al (2023) recommends this initiative be extended to the rest of the UK. A further recommendation is that all health professionals should be required to undergo specific training in all aspects of EOL care – particularly symptom management.
Communication and discharge planning
The Ambitions for Palliative and End of Life Care framework highlights good communication as an essential component to coordinated care (NHS England, 2021). Discharge planning plays an essential role in handing over care from inpatient to community teams (Merlane and Booth, 2020). NICE (2019) conducted a literature review of studies related to discharging EOL patients and transition from hospital to community settings. The study concluded that no relevant research could be identified (NICE, 2019). This is extremely concerning and demonstrates the urgent requirement for research in this area of practice.
Merlane and Booth (2020) used the Leadership Alliance for the Care of Dying People's (2014) five priorities in the One Chance to Get it Right document to create a framework that allows for safe discharge of patients at EOL. While the authors acknowledge that the One Chance to Get it Right document is somewhat dated, the advice of 21 organisations, all with a vested interest and expertise in EOL care is a valuable resource given the limited nature of the available literature (Leadership Alliance for the Care of Dying People, 2014).
The most important point Merlane and Booth (2020) described, concerns discussion with the patient's GP. Sending a discharge summary to the patient's general practice is not sufficient to ensure that primacy of care is effectively handed over to community services. Merlane and Booth (2020) also acknowledged the importance of providing the patient with an emergency healthcare plan and discharge letter, both of which are invaluable resources to paramedics who are not familiar with the patient.
There is no standardised emergency healthcare plan across the UK, which poses as a significant organisational barrier in the delivery of EOL care. Ambition three in the Ambitions for Palliative and End of Life Care framework is maximising comfort and wellbeing, and this suggests care plans should document the patient's preferences and priorities (NHS England, 2021). Ambition four suggests that records should be shared with all health professionals involved in the patient's care (NHS England, 2021).
In London, patients have the option to create a universal care plan that enables their wishes to be shared between health professionals and services including local ambulance services, out-of-hours GPs, community nurses, palliative care teams and the patient's general practice (NHS, 2025). The Universal Care Plan online system is an efficient way to communicate essential information between health professionals and ensure decisions are made in line with the patient's wishes. Therefore, a recommendation is that the Universal Care Plan system should be implemented as a matter of urgency across the whole of the UK to ensure effective sharing of information.
Advanced care planning
Advanced care planning allows clinicians to provide individualised care when a patient no longer has capacity to advocate for themselves (NHS England, 2021). Advanced care plans are not legally binding but can be used to guide health professionals to make decisions in the best interest of the patient, whether that be to start or withhold treatment (NHS England, 2022). Care plans can also consider social wishes such as preferred place of care, patients' priorities or family involvement in their death (British Geriatrics Society, 2020).
When a patient lacks capacity, decisions must be made in their best interests as per principle 5 of the Mental Capacity Act 2005. This act states that the patients' wishes, especially those documented when the patient had capacity, must be considered when making best interests decisions.
Ambulance clinicians have no knowledge of the patient let alone an established relationship before entering their home. Therefore, advanced care plans are an essential resource to ensure patients receive individualised care (Patterson, et al, 2019). Patients aged >70 years believe that advanced care planning led by health professionals benefits their current and future health by allowing for patient-centred planning (Bielinska, et al, 2021). The presence of emergency care plans is an effective solution to information sharing if they are regularly updated to reflect the patient's condition and accessible to the patient's multidisciplinary care teams (Patterson et al, 2019). Despite having a small sample size of 10 interviewees, the Patterson et al (2019) study highlighted the importance of advanced care plans being shared on the electronic record to improve paramedic confidence in decision-making for palliative patients. This study is a first step in recognising accessible care plans as an essential component in community EOL care.
The evidence is clear that advanced care plans are still not being discussed or introduced by health professionals.
Seydel et al (2022) identified nurse discomfort as a barrier to communicating with patients and their caregivers about EOL care. Sutherland (2019) had a similar perspective in reference to doctors and medical students who also feel uncomfortable having EOL discussions. In the authors' clinical experience, it is often unclear which health professionals are responsible for having EOL discussions. Having no established responsible party leads to the assumption that advanced care planning and EOL discussions have been conducted by another health professional.
Advanced care planning also allows ambulance clinicians to manage reversible conditions that may not be caused by the patient's palliating disease and may benefit from hospital admission (Blackmore, 2022).
The Ambitions for Palliative and End of Life Care framework (NHS England, 2021) recognises that carers often experience distress as a result of there being multiple health professionals working independently of each other. It is the responsibility of all health professionals to be involved in EOL care conversations and planning to ensure both the patient and carers are supported (MacKenzie and Lasota, 2020).
The JRCALC EOL guideline heavily relies on the presence of advanced care planning and does not offer guidance for out-of-hours support when the patient's care teams are not available (AACE, 2019). A further recommendation by the authors is this guideline needs to be updated in line with research to help guide ambulance clinicians to confidently make evidence-based EOL care decisions. Table 1 shows further recommendations.
| Topic | Proposed improvements |
|---|---|
| Advanced care planning | All patients with a palliative condition should commence advanced care planning from the point of diagnosis An updated care plan after every consultation or end-of-life discussion is crucial |
| Primary care provider | Patients to be assigned an accountable GP or other health professional with primacy of care in the community Patients should be reviewed regularly based on prognosis, e.g.: |
| Discharge from hospital | Verbal consultation should be held with the GP and district nursing team before discharge to make them aware of the patient's prognosis |
| Funding | An increase in NHS funding for end-of-life care should be made a priority so teams can operate 24 hours a day and prevent costly hospital admissions |
Education
Within the UK, paramedics must register with the Health and Care Professions Council (HCPC) (2018) to practise and identify as a paramedic. EOL care practice significantly differs from the life-sustaining approach paramedics are trained to adopt when providing patient care (AACE, 2019).
The varied nature of calls to ambulance services requires ambulance clinicians to have a high level of clinical knowledge and excellent skill set for holistic assessment (Blackmore, 2022). However, Givati et al (2018) advise that paramedics are not necessarily highly trained in EOL care unless they seek further education beyond a bachelor's degree.
While paramedics may be able to identify a patient as palliative, they are not experts in treating palliative conditions, nor are they able to provide follow-up care to a patient once they leave the scene (Eaton-Williams et al, 2020). Nonetheless, performing a holistic assessment allows paramedics to provide a thorough referral to other health professionals and facilitate individualised care (Murphy-Jones et al, 2021).
In the authors' experience, more paramedics are now attending EOL care courses in university after qualifying, and this should be encouraged in yearly appraisals to enhance knowledge.
Other forms of training must be considered. Shushtari et al (2022) were successful in improving competency and knowledge in EOL care after a nine-module E-Learning course. Table 2 shows further recommendations to enhance competence.
| Education approach | Proposed strategy |
|---|---|
| E-learning | E-learning courses could be implemented via the NHS electronic staff record system to provide training, with topics such as: |
| Observational shifts | Emergency health professionals may benefit from observing district nurses/community palliative care nurses to improve knowledge of caring for patients near the end of life in the community. Observing palliative care teams may increase knowledge and aid referrals |
| Further education | More paramedics should be upskilled to gain the scope of practice of an advanced paramedic practitioner in prescribing The Joint Royal Colleges Ambulance Liaison Committee (JRCALC and Association of Ambulance Chief Executives, 2019) end-of-life care guidance should be updated to offer advice regarding out-of-hours support when the patient's care teams are unavailable and for patients unknown to palliative care teams |
Conclusion
Considering the ageing population, patients are living longer with multiple comorbidities. The UK population is becoming increasingly reliant on already-overwhelmed community and palliative care services resulting in calls to 999 and inappropriate admissions to hospital. The current system is not sustainable and does not have the capacity to support future patients.
It is evident that the emergency and community sectors both have improvements to make but, to improve the healthcare system, as advocated by the charities and experts in palliative and EOL care, urgent funding and staff training is required in palliative and EOL care for all health professionals, including paramedic staff.
Without improvement in EOL patient discharge, effective interdisciplinary communication and advanced care planning, EOL care will remain suboptimal.
Calls to 999 for EOL care are becoming an increasing occurrence. Ambulance clinicians are prepared to help but need more education in EOL care as well as the support of palliative care and GP colleagues. EOL care needs to be viewed as a priority to allow parents, grandparents, children, friends, neighbours and other loved ones to die with dignity in their preferred place of care.