Plan for paramedics to do more to support palliative patients die peacefully at home

Paramedics could play a bigger role to help palliative care patients achieve their wishes to die at home under a proposed national framework, which may also help ease pressure on emergency departments.

Developed after consultation with paramedics, palliative care doctors, GPs, carers with lived experience and others – representing six countries and all Australian state jurisdictions – the proposed framework seeks to embed palliative care into paramedics’ core business and reduce needless transports to hospital.

The framework, published in leading international peer reviewed journal, Palliative Medicine, gained consensus from the group of experts on 32 different service changes to standardise best practise for paramedics delivering palliative care in community-based settings.

Lead author, Dr Madeleine Juhrmann, a trained paramedic, Research Fellow at Flinders University, and PhD graduate of the University of Sydney said there is a growing demand for palliative care services worldwide and rising preferences for home-based deaths, accelerated by the COVID-19 pandemic.

“Many palliative care patients have expressed a clear wish to die at home with family and don’t want to be transported to hospital in an ambulance following straightforward pain management by a paramedic.” Dr Juhrmann said.

In the journal article, Dr Juhrmann said paramedics already play an integral role in providing unscheduled palliative care to patients in community-based settings. However, this can vary significantly and needs to be supported.

“Paramedics are uniquely placed to respond to palliative and end-of-life care patients in the community, particularly after-hours when specialist palliative care services might be unavailable,” she wrote.

“When adequately trained and supported, paramedics can enhance person-centred care, reduce avoidable hospitalisations and facilitate one’s preferred place of death.”

Dr Juhrmann’s research, supported by leading health and aged care provider HammondCare, suggest paramedics could be helped to make complex clinical palliative care decisions with confidence and navigate care pathways that prioritise referral functions to other community-based palliative care providers.

Some of the framework’s key components to boost the role of paramedics in palliative care include:

• Providing paramedics access to electronic medical records to view patients’ advance care planning and palliative care details in real time.
• Ambulance services maintaining best practice palliative and end-of-life care guidelines, including the ability to deliver specific sub-cutaneous medications for common end-of-life symptoms without transport.
• Incorporating and connecting paramedics to localised palliative care referral pathways, including alternative referral destinations beyond an Emergency Department.

Leonie Jamieson was pleased that her husband was able to die peacefully at their Port Noarlunga home after receiving palliative care support from paramedics. Her experience illustrates how paramedics can contribute to a good death at home.

Paramedics visited Ms Jamieson and her’ husband, Neil, — who died in 2019 from Mesothelioma aged 72 – twice in his final 24 hours. Ms Jamieson was relieved the ambulance officers respected his wishes to not be intubated and taken to hospital, as per his advance care directive form.

“I had to get the form, which the paramedics read through very thoroughly and then said, ‘Yep, we completely understand’, Ms Jamieson said. They then put the form aside and “explained to me how to make Neil more comfortable”.

South Australian Ambulance Service Extended Care Paramedic and Team Leader Andrew Noble participated on the expert panel that developed the framework.  

“This research will aid ambulance services enormously in developing policies and practices which are consistent across the country, and informed by best practice and the specific needs of palliative patients who wish to remain at home,” Mr Noble said.

The framework was developed as part of Dr Juhrmann’s PhD studies, supported by the HammondCare Foundation, and supervised by HammondCare’s Professor Josephine Clayton. Next steps include engaging a multidisciplinary team to develop an implementation strategy, addressing any obstacles to applying the framework into policy and practice.