Emergencies often occur in palliative care patients and in end-of-life situations. Because of deficient palliative care structures, EMS is frequently sent to these situations even though it is not their core competency and they cannot provide the required care in the domestic surrounding.
In addition, EMS is often not sufficiently educated in the field of palliative emergencies. This can lead to hospitalization and direct conflict with the patient’s wishes. We believe the answer is in the establishment of palliative care team, as outlined in the case example that follows.
The Call
The prehospital emergency medical team is dispatched to a terminally ill cancer patient with an altered mental status, dyspnea, decreased response to verbal stimuli and cachexia (also known as “wasting,” the loss of weight, muscle atrophy, fatigue, weakness, significant loss of appetite in someone who is not actively trying to lose weight) and increased care requirements.
The physical examination shows tachycardia (heart rate 120/min.), hypotension (80/60 mmHg), peripheral oxygen saturation (75%) and lip cyanosis.
As reported by family members, the patient was discharged on his own will from the hospital with infaust (unfavourable) prognosis. No palliative care team was involved.
Upon assessment, EMS administered oxygen and started an intravenous crystalloid drip infusion. After treatment, the patient was able to better communicate and declared his will not to be hospitalized.
Family members confirmed the patient’s wishes, but also admitted they felt unable to cope with the complex situation. The EMT cannot contact the family doctor or any other medical provider or conventional caregiving support.
From the point of view of the EMTs in this situation, the patient was not guaranteed adequate medical treatment at home. The solution for this conflict is the immediate response of an ambulant palliative care team–a formal cooperation of EMS and ambulant palliative care team called Palliativnetz Osthessen, which has been in place since 2010 in the administrative district of Fulda (a rural region in the German state of Hesse with approximately 220,000 inhabitants).
Palliativnetz Osthessen provides 24/7 medical support, caregiving and support of engaged family members while meeting the patient’s distinct will to stay at home. This avoids ethical conflicts in this legally ambiguous situation.
Based on this cooperative program and response system, the EMT is able to contact the ambulant palliative care team and ensure immediate adequate support in the ambulant setting. Medical, legal and ethical conflicts are resolved and patient’s care is ensured.
Discussion
In emergencies, palliative patients declare their will to stay at home and avoid hospitalization. Emergency calls in the palliative context are often not just a call for medical emergency aid, but a call for support, especially in acute exacerbation of stressful symptoms. However, patients and caregivers are often unable to cope with emergencies and provide adequate psycho-social and medical support.
To provide effective care and therapy, emergency medical crews need special knowledge concerning specialized medical aid, required psycho-social support, ethical aspects and consideration of legal aspects.
The patient’s will to stay in the domestic surrounding has to be respected and accepted both by family and caregivers. But what can EMS systems do if their present medical care framework is inefficient in this area? We believe that a well-designed, cooperative effort between ambulant palliative care teams and emergency medical teams can provide solutions that meet the palliative patient’s will.
The percentage of emergencies concerning palliative patients suffering from advanced life-threatening diseases makes up approximately 3 % of all prehospital emergencies in Germany. Palliative emergencies are complex, multifactor events that require a broader approach compared to other conventional emergencies.
The World Health Organization defines palliative care as “an approach that improves the quality of life of patients and their families facing the problem associated with life-threatening illness through the prevention and relief of suffering by means of early identification and impeccable assessment and treatment of pain and other problems–physical, psychosocial and spiritual.”1 WHO references the following key impacts of palliative care:
- It provides relief from pain and other distressing symptoms;
- Affirms life and regards dying as a normal process;
- Does not intend to either hasten or postpone death;
- Integrates the psychological and spiritual aspects of patient care;
- Offers a support system to help patients live as actively as possible until death and helps families cope during the patient’s illness and in their own bereavement;
- Uses a team approach to address the needs of patients and their families, including bereavement counselling, if indicated;
- Enhances a patient’s quality of life, and may also positively influence the course of illness;
- Is applicable early in the course of illness, in conjunction with other therapies that are intended to prolong life, such as chemotherapy or radiation therapy; and
- Includes investigations needed to better understand and manage distressing clinical complications.1
After successful treatment of stressful symptoms, palliative care patients often refuse to be hospitalized. In this situation, conflicts can arise due to differing perspectives concerning the patient’s requirements related to adequate treatment and care. Often a conflict exists if domestic care and medical treatment is inefficient, but the patient categorically rules out the possibility of hospital treatment.
Conclusion
This case study describes a well-organized formal cooperation to provide optimized treatment and care for palliative patients. This formal cooperation between EMS and palliative care teams is currently an example of effective patient care in select districts of Germany, and we believe their expansion to other areas must be postulated urgently.
Reference
1. World Health Organization. WHO definition of palliative care. Retrieved Jan. 5, 2017, from http://www.who.int/cancer/palliative/definition/en/.
