Palliative paramedicine: Comparing clinical practice through guideline quality appraisal and qualitative content analysis

Abstract

Background: Palliative care is an emerging scope of practice for paramedicine. The COVID-19 pandemic has highlighted the opportunity for emergency settings to deliver palliative and end-of-life care to patients wishing to avoid intensive life-sustaining treatment. However, a gap remains in understanding the scope and limitations of current ambulance services’ approach to palliative and end-of-life care. Aim: To examine the quality and content of existing Australian palliative paramedicine guidelines with a sample of guidelines from comparable Anglo-American ambulance services. Design: We appraised guideline quality using the AGREE II instrument and employed a collaborative qualitative approach to analyse the content of the guidelines. Data sources: Eight palliative care ambulance service clinical practice guidelines (five Australian; one New Zealand; one Canadian; one United Kingdom). Results: None of the guidelines were recommended by both appraisers for use based on the outcomes of all AGREE II evaluations. Scaled individual domain percentage scores varied across the guidelines: scope and purpose (8%–92%), stakeholder involvement (14%–53%), rigour of development (0%–20%), clarity of presentation (39%–92%), applicability (2%–38%) and editorial independence (0%–38%). Six themes were developed from the content analysis: (1) audience and approach; (2) communication is key; (3) assessing and managing symptoms; (4) looking beyond pharmaceuticals; (5) seeking support; and (6) care after death. Conclusions: It is important that ambulance services’ palliative and end-of-life care guidelines are evidence-based and fit for purpose. Future research should explore the experiences and perspectives of key palliative paramedicine stakeholders. Future guidelines should consider emerging evidence and be methodologically guided by AGREE II criteria.

‘Mum, I think we might ring the ambulance, okay?’ A qualitative exploration of bereaved family members’ experiences of emergency ambulance care at the end of life

“…15,16 Most ambulance personnel in Aotearoa New Zealand are authorised to provide symptom relief, verify death in the field as well as terminate or withhold resuscitation in accordance with Clinical Procedures and Guidelines. 17,18 Many of those attended by an emergency ambulance will be in the last days of life, but few have a documented plan for end of life care. 6,19…”

‘It breaks a narrative of paramedics, that we’re lifesavers’: A qualitative study of health professionals’, bereaved family members’ and carers’ perceptions and experiences of palliative paramedicine

“…Some participants expressed strong-held beliefs of restricted time on scene and the necessity to treat and transport all patients to hospital, which are seemingly driven by individual perceptions, creating a culture of paramedicine at odds with what is reflected in clinical practice guidelines and accordingly permitted by ambulance service management. 12 Furthermore, community expectations and media responses to ambulance waiting times could be proliferating these assumptions. Future research could investigate strategies for overcoming such cultural norms, potentially enabling a smoother transition for paramedics to reduce avoidable hospital admissions and facilitate more home-based deaths.…”

“…1 However, the scope of palliative paramedicine practice remains heterogenous across the country: only five of eight Australian ambulance services have palliative care specific clinical practice guidelines to standardise practice, and many jurisdictions rely solely on specialist roles, such as Extended Care Paramedics (ECPs), to deliver palliative and end-of-life care in the community. 12…”

“…Virtual semi-structured interviews were conducted via Zoom between November 2021 and April 2022. Development of separate interview guides for health professional participants and family/carer participants was informed by discussions with the study-created Australasian Palliative Paramedicine Advisory Group (a multidisciplinary community of practice comprised of jurisdictional palliative care and paramedicine representatives), a comparative policy study of Australian and Anglo-American palliative paramedicine guidelines, 12 and a systematic integrative review on the topic. 8 Interview guides were then pilot tested amongst the research team.…”

“…2,3 As a result, paramedic practice is diversifying to include community paramedicine models, [4][5][6][7] and growing expertise in palliative and end-of-life care. [8][9][10] Yet, as paramedics respond to increasing numbers of palliative and end-of-life care patients in the community, the traditionalist orthodoxy of treatment and compulsory transfer to hospital is being questioned 9,10,11 Palliative paramedicine clinical practice guidelines 12 and training programmes 4 are emerging, alongside interdisciplinary palliative care teams that include paramedics, 13 to broaden scopes of practice and facilitate more homebased deaths. However, paramedics reportedly still lack the skills, confidence and clinical support to provide palliative and end-of-life care in the community.…”