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emergency
care pathway
end of life
prehospital

Palliative emergencies in the pre-hospital setting

02 October 2014
Features
02 October 2014
Volume 6 · Issue 10

Abstract

Objective: To provide a narrative on the most common palliative emergency situations that requires the attendance of a paramedic. This narrative looks specifically at pain, seizures and breathlessness, and critiques the underpinning evidence supporting their treatment and protocols.

Discussion: Pain—the presence of pain in palliative care is highly prevalent with up to 70% of patients living in a permanent painful state. Clinician-led pain assessment has been shown to underestimate the patient's pain by as much as 60–68% and none of the assessment tools used are fully inclusive. Further research is needed to formulate an assessment tool that recognises palliative pain as a progressive disorder requiring constant assessment.

Seizures—Seizures occur as either a result of disease progression or as a side effect of medications. Studies have shown that intramuscular midazolam is more effective than intravenous lorazepam, which is itself more effective than intravenous diazepam. The ease of administration of intramuscular and buccal midazolam for out-of-hospital use should make midazolam the first-line treatment for palliative care patients that suffer from seizures. The implication for future paramedic practice highlighted from these studies is the need for more research in the treatment of palliative patients with seizures.

Breathlessness—Cold facial stimulation has been shown to be very effective as a non-pharmacological treatment for breathlessness. Opioids help to relax the patient which aid in regulating breathing patterns although a consensus on the route of administration which provides the best possible effect is yet to be reached. The evidence base for the use of anxiolytics is weak and some studies have shown no beneficial effect to their use. Although anxiolytics are effective in reducing anxiety their effectiveness in helping breathlessness in palliative patients is questionable. Home oxygen should be adopted as a first line treatment according to experts working in end-of-life care, and treatment of oxygen should not be delayed by waiting for results of other trials for other treatments.

As the pressure on paramedics to ‘see, treat and refer’ gathers momentum, and the ever increasing demand on the Accident and Emergency department urges paramedics to seek an alternative care pathway, the need for education and research into palliative (end-of-life) emergencies comes to the fore. Palliative emergency care is an ever-increasing concern for today's ambulance services where key words such as breathlessness, pain, and seizures, frequently result in an emergency response. Research into a typical day of the ambulance service shows that approximately 33% of paramedics will see a terminally ill patient at least once a shift, and 29% every two shifts (Munday et al, 2011). This highlights the importance of the role of the paramedic for the palliative patient, and the need for a greater understanding of end-of-life care. The introduction of the non-emergency ‘111’ and ‘NHS direct’ services has fuelled demand on the ambulance Trusts to care for the palliative patient, and this increased demand, accompanied by the lack of guidance from the Joint Royal Colleges Ambulance Liaison Committee (JRCALC), places the paramedic in an unprecedented position of being asked to perform a role for which they have minimal training (National End of Life Programme, 2012). More often than not, the end result is transport to an Accident and Emergency department, where the patient is taken from the comforts of their own home and into a busy and uncomfortable hospital environment, only to be released without further treatment. Pre-hospital care in the UK has become very regionalised, with some areas having more options to help palliative patients than others. Community-based services and 24-hour clinical support is often fractious and the only option for a lot of patients is the ambulance service.

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Breathlessness
Dyspnoea
End-of-life care
Palliative care
Pain
Seizure