Palliative Medicine for the Community Paramedic

Elderly sick man lies in bed with oxygen catheter on the palliative care unit or at home — Shutterstock/Robert Kneschke

The role of the paramedic is evolving. No longer are we as a profession “ambulance driving” our customers and clients to the hospital. EMS has become a catch-all, a gateway into a somewhat—if not totally—fractured healthcare system.

This is a system where patients and their families can be subjected to long, drawn-out treatments for terminal disease. We see aggressive resuscitation with high-efficiency CPR, endotracheal intubation and intraosseous access literally drilled into their bones, all with minimal chance of improvement.

The role of EMS, and paramedics in particular, was always designed to be one of rapid identification of a life- or limb-threatening issue that could be deferred, minimized, or abated through protocol based definitive intervention, and a safe, rapid emergency transportation to a hospital or emergency room for definitive treatment by a physician.

The landscape of healthcare is shifting as well. The pandemic, coupled with the realization of self-care, well-being, and mental health struggles has caused drastic reduction in the number of healthcare workers, and the amount of experience in skills that those healthcare workers carried with them.

Hidden Advantages to Change

These changes do come with an upside. They create opportunities for growth in change for the following:

In-hospital care.
Emergency department care.
Outpatient care.
Pre-hospital care.

Over the past many years, we’ve seen a push for the idea of the community paramedic, as well as mobile healthcare. The establishment of a community paramedic program, especially in rural areas of the United States, would provide non-emergent care, under expanded scope and under the direction of a physician in the patient’s home.

According to a literature review in the International Journal of Paramedicine, the the most common community paramedic program goals are to “aid patients in chronic disease management, reduce emergency department visits, reduce hospital admissions/readmissions, and reduce Healthcare costs.”¹

The most common diagnoses of the patients who received coordinated community paramedic care by a rural program in Texas include the following:

Hypertension.
Dementia.
Constant falls.
Diabetes.
Chronic pain.
Respiratory issues.
Depression.
Chronic diseases with high readmission rates such as congestive heart failure, chronic obstructive pulmonary disease, chronic kidney disease or asthma.¹

Traditional paramedic education, while providing insight into pathophysiology, is primarily focused on interventional treatments, designed to alleviate symptoms, under a set of standardized protocols. We are taught not to diagnose, but to suspect and intervene on subjective symptoms and objective exam findings.

Expanding the scope of paramedics through additional post-graduate education provides an opportunity to be a part of an interdisciplinary team that includes the following providers:

Primary-care providers.
Home-care providers.
Visiting nurses.
Social workers.
Mental health workers. Emergency department providers.
Specialists.

The team also includes family members and, most importantly, the patients themselves.

Palliative medicine is a medical specialty area. It exists to help patients and their families cope with chronic and serious illness, and to provide excellent symptom management, psychosocial support, and assistance with difficult medical decisions and building relationships with caregivers.

“The early incorporation of palliative care, concurrent with disease directed treatments, enables patients and their families to have the best chance of maintaining the quality of life for the longest possible time.”²

Palliative Care vs. Hospice Care

One of the biggest misconceptions both within and outside of healthcare is that palliative medicine and hospice care are synonymous. While end-of-life care and hospice care do fall under the overall umbrella of palliative care, palliative care can be initiated at any point during a serious illness. It is a person- and family-oriented approach that provides relief from symptoms and stress of a chronic illness.

Palliative medicine can be initiated at the time of diagnosis of a serious illness and can be delivered alongside treatment of the disease. Hospice care, on the other hand, begins after treatment of the disease has stopped.

It is clear that the disease process is terminal, and the patient will not survive. Hospice care is reserved for patients that have an anticipated lifespan of less than six months. Hospice care is about caring, not curing.

The palliative medicine provider’s primary objectives are to do the following:

Control pain and symptoms.
Address psychosocial distress.
Assist with spiritual issues.
Assist with the patient’s and family’s practical needs.
Coordinate care, across many specialties, through high-quality communication.
Use high-quality communication skills to help patients and families obtain the information they need to fully understand the illness, prognosis, and treatment options.
Clearly communicate nonbiased information regarding the patient’s diagnosis.
Prognosticate the potential outcomes.

Difficult Conversations

Beyond the list above, having difficult conversations with patients and families regarding their goals of care is among the most important skills of a palliative medicine provider.

But this task can also be one of the most stressful situations for any provider, even those with advanced degrees. Fortunately, we have many tools and mnemonics available to us to help guide us through these difficult conversations.

Many resources include free online access such as Vital Talks and their Quick Guides. Some of the examples of these include the following:

SPIKES Protocol

Setting: Arrange for privacy, involve significant others, sit down, make connections.

Perception of condition/seriousness: Determine what the patient or family knows about the current condition or what they suspect, listen to their level of comprehension, accept denial. (Don’t confront now.)

Invitation from the patient to give information: Ask if they want to know details about the condition/treatment. Accept if they do not want more information, offer to answer questions at a later time if they change their mind.

Knowledge: Give medical facts using intelligible language that the patient or family can understand, take into consideration education levels, sociocultural background, current emotional state, language barriers. Provide information in small chunks and follow up to ensure comprehension. Provide accurate and honest facts about conditions, treatments and prognosis.

Explore emotions and sympathize: Prepare to give an empathetic response, identify the emotion the patient expresses. Use responses like, “I can see that you are angry/sad/shocked/disappointed.” Give the patient or family time to express their feelings and respond in a way that demonstrates understanding.

Strategy and summary: Close the interview or discussion, ask if there are any questions or if they have anything they would like clarified. Ask if there is anything you can offer them. Reassure them that you are available if they need you.

ADAPT Tool: Discussing Prognosis

Ask what the patient knows, and what they want to know.

What have the doctors told you about your prognosis? How much have you been thinking about the future?

Discover what information about the future would be useful for the patient.

For some people prognosis is numbers or statistics for how long they have to live, for others it is more about living to a particular date, which would be more helpful?

Anticipate ambivalence.

Talking about the future can be a little scary, from what I know about you this information may affect decisions you are thinking about. What are the pros or cons about discussing this?

Provide the information the patient wants, in the form they want it in.

Statistics – percentiles, best/worst case scenarios, median survival

Non-statistical – Situation/disease change/responding, I believe there is a good/50-50/poor /slim/no chance that you will be around by then.

Track emotion.

Use responses like the following:

“I can see this is not what you were hoping for.”

“I wish I had better news.”

“I can only imagine how this feels to you.”

“I appreciate that you want to know what to expect.”

REMAP Tool: Addressing Goals of Care

Reframe why the status quo isn’t working. The scan results have come back, so it may be a good time to discuss what to do now. We are in a different place.

Expect emotion and empathize. I can see you are concerned about (x). It is hard to deal with all of this, tell me more about what you are worried about. Is it OK for us to talk about what this means?

Map the future. Given this change, what is most important for you? As you think toward the future what concerns you the most? What do you want to do?

Align with the patient’s values. As I listen, it sounds like the most important things are (x,y,z).

Plan treatments that match values. Here are some things we can do now to address your priorities, what do you think?

NURSE Tool: Responding With Empathy

Naming: Name the emotion. It sounds like you are frustrated / angry / sad

Understanding: Offer another acknowledgment but don’t say you understand everything.

Respecting: Say, “I see you have been following our instructions. I think you have done a great job at this.”

Supporting and showing commitment: Say, “I will do my best to make sure you have what you need.”

Exploring: Ask, “Can you say more about what you mean when you say that?” This component focuses on fundamental skills, with “tell me more,” “ask tell ask” and “I wish” statements.

PAUSE Talking Map: Establishing Goals of Care Early in Illness

Pause: Make the time. Say, “There is something I would like to put on our agenda.”

Ask: Get permission and explain why. Occasionally one of my patients gets sick and I am unable to ask them these questions.

Understand big-picture values. If the disease gets worse and might be terminal what would be most important to you?

Suggest choosing a surrogate: Have you ever considered who would be the best person to make decisions for you if you got too sick to make them yourself?

Expect emotion, respond empathetically.

It is clear that the majority of these tools are not designed to be used under pressure, at the scene of an emergency, under a high stress situation. Basic knowledge of some of these skills can provide some level of comfort during difficult conversations. Some of the other ways that community paramedics can participate or potentially have an impact is understanding some of the other aspects of palliative medicine. It can also help when they understand different interventions on symptoms that can provide significant relief from suffering.

Pain Management

Excellent pain management and alleviating suffering is a course scale for any clinician or provider including the pre-hospital provider. The primary method for treating acute pain in the pre-hospital setting is opioids, which can be a very effective tool for treating pain.

Choose an appropriate opioid and inappropriate dose. This will likely require advanced scope as some of the doses are far outside the parameters of our protocols, and likely outside of the quantities of medications we carry in our standard narcotics kit.

Understanding equianalgesic dosing of opiates—how many morphine equivalents are in a dose of hydromorphone—can help you understand how to best facilitate treating the patient’s pain. You’ll find many online calculators that can help determine dosing equivalents.

Dyspnea

According to the American Thoracic Society, dyspnea is “a subjective experience of breathing discomfort.” Dyspnea can be a very distressing symptom, both to the patient who feels like they are unable to breathe with ease, and to the family who witnesses the patient struggling, suffering, and transitioning from pink to blue, witnessing cyanosis, agitation, hypoxemia and encephalopathy.

Being able to identify the patient condition that contributed to the worsening shortness of breath, and having to intervene upon them to alleviate their distress is an important skill set for any care provider. Some of the treatments are standard of care for pre-hospital providers such as bronchodilators, corticosteroids and oxygen for patients suffering from end-stage COPD. Treat their anxiety, and hypoxemia, with opioids as a first-line treatment and adding on anxiolytics to supplement symptom management.

Patients nearing their end of life often suffer from excessive secretions. They can sometimes be thick and copious, causing partial occlusions of the airways. Simple percussion of the chest may help loosen secretions and facilitate expectoration. Over-the-counter decongestants such as guaifenesin or nebulized saline may also provide some symptom relief. Something as simple as a fan set on a side table facing the patient may provide some positive pressure, making the respiratory effort slightly easier.

Gastrointestinal Symptoms

The gastrointestinal (GI) tract can cause many types of difficulties over the course of a serious illness. The alimentary canal starts at the mouth, transitions into the esophagus, stomach and intestines. Its exodus is through the rectum and anus. Complications can arise in any of these areas. Pain, a common oral symptom, could be from an infection such as yeast or staphylococcus.

Patients with poor-fitting dentures could have ulcers. Patients with native dentition can suffer from dental caries due to poor oral hygiene, decreased saliva, not allowing the body’s normal cleaning processes or just increased fatigue, when they are too tired to brush. A patient undergoing radiotherapy can suffer from dry mouth, taste disorders or osteonecrosis of the jaw following surgery or procedures.

As we progress into the oropharynx, we find patients having swallowing difficulties. These difficulties are called dysphagia. Masses, obstructing lesions, neuromuscular autoimmune etiologies that cause dysmotility, dysfunction, stenosis and even hiccups can be uncomfortable and distressing for patients, especially if they become chronic or intractable.

Obstructions, difficulty swallowing or intolerance of food, can result in the need for artificial nutrition and hydration. That could happen with a surgically placed pathway to the gut, such as a percutaneous endoscopic gastrostomy (PEG) tube, or via parenteral means such as total parenteral nutrition.

Patients with prior surgery consults for bowel obstruction, significant nausea and vomiting from chemo or from medication side effects, can be significantly distressing. Understand routes for administration of antiemetic medications that may be outside of the current scope of paramedic education but that offer opportunities for advanced scope providers to treat symptoms, whether those routes are via a feeding tube, intravenous, oral dissolving or suppository.

This may also offer an opportunity to obtain and expand the scope for using alternative medications such is haloperidol or droperidol to help with symptom relief. As we approach the end of the GI tract, we find ourselves struggling with constipation or diarrhea.

Patients receiving palliative care can suffer from constipation due to lobe intake of food or fluid, impaired mobility, difficulty ambulating to the toilet or chronic use of opioid medications, which decrease gut motility. They also may suffer from medical conditions such as bowel obstructions, proctitis or other complaints that may make passing stool difficult.

Delirium, Depression and Anxiety

Delirium is an acquired disturbance of attention on awareness that is in company age bite change in baseline cognition. It is usually something that comes on acutely. And it is usually secondary to another condition. The most common cause of delirium in a palliative care setting is likely related to medication. These can be opioids, benzodiazepines, antidepressants, muscle relaxers or corticosteroids.

However, there are medical conditions that can also cause changes in baseline mental status and cognition, such as electrolyte imbalances, renal failure, hypoxemia and hypoglycemia.

Infectious causes such as urinary tract infections, aspiration pneumonia pressure ulcers, indwelling catheter infections. Comorbidities such as constipation, urinary retention, pulmonary embolism, new stroke, or metastatic malignancy. Intervention for these symptoms would be based on the condition you’re treating.

Evaluating your palliative care patients for depression, utilizing baseline depression scoring tools, and being able to intervene on the symptoms, can provide great relief in patient suffering. Patients can also be anxious, understandably.

Early identification and recognition of the symptoms, interventional treatment including identifying treatable medical complications, and management of contributing factors such as psychological, social, physical and spiritual pain can also impact patient care. Treatment should be focused on counseling, medication, and trigger or stimulus avoidance.

Advanced-Care Planning: Goal Setting, Prognosticating and Surrogate Decision Making

Advanced care planning enables an individual to define goals and preferences regarding their future medical care. In a perfect setting, adults will start early in identifying their goals of care. These goals may change throughout a person’s lifetime. However, broaching the subject and having difficult conversations can facilitate more conversations in the future.

As the patient evolves through their life cycle, situations change. Marriages, children, retirement and insurance can all affect a patient’s goals of care. It would be best if decisions were made prior to the patient becoming more seriously ill. Serious illness can cause cognitive impairment or decline and may force the patient to be unable to communicate their goals or wishes for future care with the family.

Using surrogate decision makers and clearly documenting a patient’s wishes prior to their cognitive decline helps give caregivers and medical providers clear insight into the patient’s wishes. This also helps provide clarity among family members who may disagree with the patient’s belief systems.

Ideally this approach will minimize conflict at an already stressful time. For the community paramedic, understanding the different types of advanced-care planning can help facilitate open discussions, and can help clarify a patient’s goals of care.

Understanding the difference between a durable power of attorney, a durable power of attorney for healthcare, a living will, a physician’s order for life-sustaining treatment (POLST), do not resuscitate (DNR), comfort measures, hospice and what each of these does can help clarify the patient’s wishes.

Employing tools like the ones listed above and others such as the functional status scale, the palliative performance scale, the palliative prognostic index, and the understanding of common illness trajectories can help palliative care providers offer insight about the prediction of the course of the illness.

In addition, using tools, medical data, and experience can provide some general estimates of when a patient might experience pain. Avoid specific numbers, as it’s better to convey a prognosis in range, hours to days, days to weeks, weeks to months, etc. You want to be able to explain to the patient and their family how you obtained that information.

Conclusion

Community paramedics can play an integral role in patient-centered care, as the concept of home care returns to the forefront where it started, back when the local “doc” would come around.

Having a broad baseline of knowledge, familiarization with the terms, diagnostic tools, prognostic planners, and learning-improved communication skills through supplemental training, post paramedic education—even without diagnostic or prescriptive authority—can allow the healthcare system another opportunity to take care of patients as they need to be taken care of: with autonomy, fully informed decision making and an understanding of their treatment options, allowing them to live their best experience.

About the Author

Maurice Paquette is the deputy fire chief of the Allenstown (NH) Fire Department. He is a board- and specialty-certified ED physician assistant. He has been a firefighter since 1992, and a paramedic since 1997.

References

1. McAuslan, C., BS, Roll, J. M., PhD, & McAuslan, M., BS (2023). Goals, Services, and Target Patient Populations of Community Paramedicine in Rural United States: A Literature Review. International Journal of Paramedicine, 3, 22-33. https://doi.org/10.56068/FSCK6274

2. Periyakoil, V. S., MD, Denney-Koelsch, E. M., MD, White, P., MD, Zhukovsky, D. S., & Quill, T. E. (2019). Primer of Palliative Care (7th ed.). American Academy of Hospice and Palliative Medicine.