Paramedicine has changed dramatically throughout the last twenty years. With significant changes in both the education that underpins paramedic practice and the technology now used to enhance it. The quality of care being provided to the service-user has arguably never been so high.
What was once merely a transportation service has now made the transition into a profession with legally accountable clinicians who are expected to base their decisions on the most up-to-date, available evidence. With this increased responsibility however, comes increasingly higher expectations to protect and preserve life and patient outcome.
It might be argued that for the majority of practitioners, death is viewed primarily as a defeat in the face of an uncontrollable force of nature, one that will undoubtedly affect us all at some point of our personal and professional lives and that all should be done to prevent it; especially at this festive time of year.
However, the concept of paramedics being able to assist in the provision of a ‘good death, a peaceful death, or helping someone to die well’ is one that is often misunderstood, shrouded in fear of de-registration, punitive repercussions and generally lacking in evidence-based research (Nellist, 2011).
Until about 1970, the concept of death was not open for discussion in healthcare and remained a subject actively avoided in conversation with terminally ill patients—professionals generally favouring the provision and engendering of false hope as a means of comfort (Goldsteen, 2006). Since then it has been recognised that patients, families, friends and carers should be empowered and given the autonomy to decide where, how and with who they should die. Factors such as ‘freedom from pain, dying in one's favourite place/environment, having a good relationship with medical staff, maintaining dignity, and perhaps most importantly maintaining a sense of control’ have all been identified as attributing to a ‘good’ death (Hirai et al, 2006) and fall well within the remit of variables paramedics can potentially control.
‘…for the majority of practitioners, death is viewed primarily as a defeat in the face of an uncontrollable force of nature…’
The concept of allowing someone to die in the manner in which they would like has recently been supported by the Department of Health (DH) who announced a move towards giving people more choice and support in their preferences to achieving a ‘good’ death (DH, 2010). However, this move has been against the backdrop of more recent conflict surrounding landmark cases involving patients with locked in syndrome, highlighting the potential conundrum paramedics may face in acute practice.
By removing the taboo and stigma related to what is, in essence, very much a part of everyday life, encouraging discussion and debate early on in paramedic education and involving multi-disciplinary teams to allay fears and to promote best practice, paramedics can play a very real part in providing a ‘good’ death to those patients expected to die who we very often get called to in times of fear, desperation and distress.
Paramedic education, which now stands at university level, has started to broach the subject of death in more depth. It now recognises the myriad of emotions paramedics are exposed to relating to suffering, pain and most pertinently of all, death (Williams, 2012). Educators are taking tentative steps to break down the taboo related to perhaps the only area of practice that practitioners will not only assist in, but one day actually experience themselves. Death education within paramedicine has, up until very recently, arguably only focused on the legal, practical and professional issues and not the equally important concepts of peace, comfort and family-centred care during death. Dickinson et al (2008) highlight the important role nurses play in end of life care, and recognise that the nursing curricular should include these topics in their course provisions in order to give students the opportunity to face the issue of death, therefore allowing them to be better prepared to help their patients and their families to do so. Given the similarities between the two professions and the environment in which paramedics work, this author suggests that all paramedic education should involve some form of instruction surrounding the provision of a ‘good death’; for both pre- and post-qualified practitioners. Paramedics need to be less afraid of raising the sensitive subject of death with families' carers and, most importantly, those dying patients they attend. Emanuel et al (2004) highlight that many people think that speaking with patients on the subjects of death, dying and their terminal condition is likely to cause stress; however one argues that the uncertainty, unknown and possibility of one's loved one dying in pain or discomfort is more likely to cause stress and anguish. This highlights the need for paramedics to embrace certain aspects of death as a pedestrian normality, which could actually benefit from their professional contribution.
Harking well back to the days of the authors own fathers' death, concepts of a painless, calm, relaxed transition involving close family members and favourite music playing in a comfortable environment, highlights the ease in which a ‘good’ death can actually be achieved.
‘Paramedics need to be less afraid of raising the sensitive subject of death with families' carers and, most importantly, those dying patients they attend…’
Paramedics should be proud to be part of a profession that wants to face these professionally and ethically complex situations that are often emphatically and emotively charged, and should do so head on, to provide high quality care both in life and very much in death.