Paramedics encounter death regularly owing to the nature of being first responders to a variety of health-related emergencies. It is also the reality that patients may have poor outcomes such as death and disability.
In 2018, paramedics attended 7874 out-of-hospital cardiac arrests (OHCAs) in New South Wales, Australia (Dyson, 2020). Approximately 27% of these patients survived to the emergency department (Dyson, 2020). Given the statistics on OHCA outcomes, it is reasonable to assume that a paramedic will witness the death of a patient.
Paramedic students may not have witnessed death before a work placement or internship. This may be a stressful experience and could influence their mental wellbeing. Paramedics are often required to communicate death notifications and support to families or other people close to the patient and may have personal struggles when confronted with death.
Most paramedic courses aim to prepare students for the realities of the profession but it is not clear how effective they are in preparing graduates for witnessing death.
This paper aims to assess the quantity and quality of paramedic death education using a scoping literature review; implications for future research will be identified. The research question is: ‘Are paramedic graduates effectively prepared for death?’
Methodology
Scoping reviews describe the existing literature and provide a broad overview of the area (Peterson et al, 2017; Sucharew and Macaluso, 2019; Lawn et al, 2020).
Psychological effects and interventions for the mental wellbeing of paramedics have already been well documented (Alden et al, 2020; Joanna Briggs Institute, 2020). Research has shown that non-technical and mental wellbeing skills were often not taught by paramedic educational providers as part of undergraduate education or on-the-job training (Anderson, 2020).
A scoping review was chosen to provide a brief overview of recent research concerning death education and was deemed appropriate for the research question. A thematic analysis was then carried out to interpret the resulting articles (Nowell et al, 2017).
The PRISMA flow chart details the search strategy used with the inclusion and exclusion criteria (Figure 1) (Page et al, 2021). Records were identified from databases and from the Charles Sturt University library. The aim of the five-year time span (2016 to 2020) was to identify new and emerging literature concerning death education. The keywords ‘paramedic’, ‘death’ and ‘education’ were used. Initially, the author intended to limit the review to Australian studies. However, owing to paucity of literature, relevant international articles were considered, including studies from New Zealand, the United States and the UK.
While the research question focused on paramedic graduates, articles regarding paramedics throughout their careers were included. While this was because of the lack of literature, it was also deemed relevant to the research question since paramedics are required to engage in education and training as part of continuing professional development (CPD).
Specific areas of research were considered, such as termination of resuscitation decision-making processes, death notification delivery, and disaster and mass-casualty incidents. The author aimed to focus on death education, which relates to these areas, but excluded articles on clinical management of mass-casualty and disaster incidents.
Eighteen relevant articles were identified (Appendix 1, online). Thematic analysis was performed in four phases.
Phase one consisted of the author familiarising themselves with the data and occurred simultaneously with the search strategy and independently after relevant articles were identified.
Phase two included compiling data in a table (Appendix 1, online) for ease of reading and comparison between articles. Themes and subthemes were generated during this phase through inductive reasoning and evolved throughout the thematic analysis.
Phase three consisted of reviewing the themes generated and identifying patterns between them.
Phase four consisted of the analysis of the findings as discussed below.
Results
Through thematic analysis, four themes were identified. These include: inadequate preparation; methods of death education; improved confidence; and implications for more research.
There were a mix of literature reviews, qualitative and quantitative studies, and some grey literature. The key findings of each individual article are listed in Appendix 1 (online); however, the key findings in the articles included appear to be cohesive and consistent. Since the literature is consistent regarding death education, the weight and rigour of the argument for death education is strengthened. Overall, the mix of articles in the review provides a sufficiently broad overview of death education in paramedics with minimal inconsistencies.
Inadequate preparation was identified as a key theme in several of the articles (Brady, 2016; Tataris et al, 2017; Mainds and Jones, 2018; Walker, 2018; Anderson et al, 2019a; 2019b; Pentaris and Mehmet, 2019; Campos et al, 2021). The literature was consistent in this area, finding that paramedics largely felt inadequately prepared for death by their paramedic programmes. Both qualitative and quantitative studies showed that student paramedics would benefit from a death education programme (Anderson et al, 2019c; 2020; McConnell, 2019; Campos et al, 2021).
Methods of death education varied in the literature, however, all were shown to be appropriate methods of delivery. These methods were not compared with those of other death education programmes. Some of the methods involved online, self-paced programmes (McTague et al, 2019), learning through supportive mentoring (Anderson et al, 2019b; 2020), and exposure and experience (Anderson et al, 2019a; 2019c; 2020).
Other factors regarding the delivery and the logistics of death education included standardisation of education (Campos et al, 2021), the use of cognitive tools (Walker, 2018), effective low-cost approaches to education and group education (McConnell, 2019; Skehin et al, 2020), the use of supporting sciences and multidisciplinary approaches (Nicell et al, 2017; Pawley et al, 2017; Lazarsfeld-Jensen, 2019; Skehin et al, 2020), and the involvement of mental health and resilience education (Lazarsfeld-Jensen, 2019; Pentaris and Mehmet, 2019).
Death education was consistently associated with improved paramedic confidence in performing death notification and managing patient death in the articles (Kirk et al, 2017; Nicell et al, 2017; Pawley et al, 2017; Anderson et al, 2019c; Fairhead, 2019; McConnell, 2019; McTague et al, 2019; Campos et al, 2021). This was evaluated largely through quantitative methods.
Some of the articles discussed the benefits of simulations and rehearsal of death notifications, managing patient death and termination of resuscitation (Nicell et al, 2017; Fairhead, 2019; McConnell, 2019). Death education for specific patient groups, such as children, or in end-of-life care was found to be effective (Brady, 2016; Kirk et al, 2017; Nicell et al, 2017; Pawley et al, 2017; Fairhead, 2019; McTague et al, 2019; Skehin et al, 2020).
Implications for further research were mentioned in several studies. Further research was also the focus of two literature reviews (Anderson et al, 2019a; Pentaris and Mehmet, 2019). However, it was argued in one paper that the lack of research surrounding paramedic death education was not actually preventing improvements in services or education in end-of-life care (Pentaris and Mehmet, 2019; Appendix 1).
Discussion
The four themes that were identified from the scoping review were: inadequate preparation; methods of death education; improved confidence; and implications for more research.
Inadequate preparation as a theme was not surprising. Prehospital care by its nature requires clinicians to manage challenging situations, such as mass-casualty incidents, trauma presentations, situations that need de-escalating, as well as death and dying. Paramedics are required and expected to cope with many distressing presentations, despite a lack of adequate preparation.
With Australian paramedic programmes being largely university based, many students may be young, lack life experience, have limited emotional resilience skills or do not understand the emotional requirements of prehospital care. Through effective death education at university level and throughout the career of a paramedic, burnout could be mitigated, which improves the sustainability of the workforce (Campos et al, 2021). The practical and emotional skills involved with death education such as termination of resuscitation decisions, death notification and delivery, documentation surrounding death, and scene management of a dead or dying patient have been identified as important areas of teaching (Anderson et al, 2019a; Pentaris and Mehmet, 2019).
The literature showed a consistent association between death education and improved paramedic confidence. Higher levels of comfort and preparedness were reported by paramedics who had undertaken death education or rehearsal of non-technical skills through their paramedic programmes or through their ambulance service (McConnell, 2019; Campos et al, 2021). The rehearsal and preparation of paramedic students for the routine aspects of death, such as termination of resuscitation, communication and documentation of death as well as scene management involving death, benefit students and experienced clinicians alike (Kirk et al, 2017; Anderson et al, 2019c; McConnell, 2019; Campos et al, 2021). Discussion surrounding emotionally demanding deaths, such as paediatric deaths and in end-of-life care, can contribute to the overall wellbeing and emotional resilience of clinicians when managing these difficult cases (Nicell et al, 2017; Pawley et al, 2017; Fairhead, 2019; McTague et al, 2019).
For these reasons, existing paramedic death education at student level, such that as in universities or in paramedic programmes, may benefit from an being evaluated. This could involve a review of current methods and programmes for death education in universities. Data could be obtained about the effectiveness of programmes by using quantitative methods, such as a survey method. The effectiveness of new programmes could be determined using data from before and after surveys. Assessing the current standard of death education in Australian universities and paramedic programmes is vital if they are to be improved.
Paramedic organisations may also benefit from supporting a death education programme that meets CPD needs. It was identified that there are various methods of death education to suit different educational needs and workplace cultures. Delivery of death education, which could be adjusted based on context (university or paramedic organisation) ideally would be flexible and cost-effective. Online, self-paced programmes may be more suitable for distance education students, whereas a supportive mentoring system may be easier to implement for on-campus students.
Collaborating with supporting sciences, such as psychology, education and law, could allow a holistic approach to death education to be taken and expansion into an overall emotional resilience course. While this approach would cost more, it could also be not limited to paramedic schools but also include nursing, criminal justice, psychology, and allied health profession students.
Gaps in knowledge were identified regarding death education for Australian paramedic students and international paramedic students, as well as in informal methods of death education. Studies into death education that is already provided would be beneficial for the preparation of future paramedic graduates.
This study argues that it would be beneficial to implement or develop death education through universities and paramedic programmes, incorporating the rehearsal of non-technical skills (in death notification, communicating and supporting a family, and managing the scene of a patient death) with resilience and mental wellbeing factors.
Further studies into paramedic death education at a student level may be required to assess effectiveness of the programme and to evaluate any associated skill decay. Recent research into Australian paramedic death education is minimal and focused research may be needed to determine the effectiveness of death education through Australian paramedic programmes. Research to compare the effectiveness of death education depending on the methods employed could also be indicated.
Study limitations
There are some limitations to this scoping review that should be taken into consideration. The first is that relevant articles may have been inadvertently omitted during the screening process. Another limitation is the review's narrow focus. A wider focus could have included topics such as emotional resilience in paramedics.
Additionally, the chosen time span of 5 years is a limitation. Paramedic programmes have been running for much longer than 5 years and this scoping review does not allow for a comprehensive analysis of how these programmes have changed. Expanding the time span could allow themes in death education to be compared over time and better inform recommendations for improved death education delivery.
Conclusion
This scoping review summarised recent studies into paramedic death education. In the past 5 years, 18 articles have been published in this area, with four themes identified: inadequate preparation; methods of death education; improved confidence associated with death education; and implication for more research.
Paramedics largely felt inadequately prepared for death in the professional setting, including carrying out tasks such as death notification, managing patient death and supporting the bereaved.
Adequate death education made paramedics to feel supported and more confident when performing these roles throughout their career. While further research is required, implementation of programmes at the student level is argued to be beneficial and achievable at low costs.