As Australia’s population continues to age the demand for palliative care services is also increasing. According to the Australian Institute of Health and Welfare, tertiary health facilities saw a 19.2 per cent rise in palliative-care related hospitalisations between 2010 and 2015. [1] And despite most of us (70 per cent) wanting to die at home, only 14 per cent of Australians currently have that wish granted. [2] Comparatively, 54 per cent of people die in hospitals and 32 per cent in residential aged care facilities. [2]
One interface capable of improving these statistics to better reflect community preferences is paramedicine. Paramedics have the unique potential to facilitate patients in fulfilling their end-of-life wishes at home. However, their scope of practice has traditionally been limited to providing life-sustaining interventions for acute emergencies. A recent study of Australian paramedics’ knowledge and attitudes towards their role in delivering palliative care revealed significant gaps in clinical competence and comprehension of relevant health law. Research from the United Kingdom highlighted similar issues, where paramedics reported minimal education in palliative care, especially around end-of-life treatment. [3] Further, most Australian ambulance clinical practice guidelines (CPGs) fail to reference palliative care beyond the legal aspects of an advanced care plan.
In order to reduce hospital-based deaths, we must integrate the planning and delivery of community-based palliative care into ambulance services’ systems of care. Both the South Australian Ambulance Service (SAAS) and NSW Ambulance have developed innovative models to improve palliative care service provision within their states.
SAAS embarked on a joint initiative with SA Health in 2008 to establish the role of an Extended Care Paramedic (ECP). ECPs are highly skilled clinicians who work beyond the normal scope of paramedic practice, collaborating with other health care professionals to manage and treat patients within their place of residence. Since the program’s inception 11 years ago, ECPs have treated a range of chronic health conditions and provided alternate care pathways for patients to help avoid unnecessary trips to the hospital. Within the context of palliative care, ECPs can treat patients suffering from breakthrough pain in their own home 24 hours a day, rather than transferring them to the Emergency Department (ED) for treatment.
Across the border in NSW, this effective model of community paramedicine had been operating since December 2007. NSW Ambulance describes the underpinning goals of an ECP paramedic in providing care to a palliative patient to include:
- Providing a safety net for unplanned health issues;
- Maximising comfort for the patient;
- Maintaining dignity for the patient and being an advocate for their wishes;
- Ensuring adequate analgesia by relieving pain and discomfort; and
- Controlling other symptoms with the aim of enhancing the patient’s quality of life and alleviating or minimising their fear and anxiety.
NSW Ambulance also established the Coordinator of Palliative and End of Life Care role in 2017, employing an experienced palliative care clinical nursing consultant to raise the profile of NSW Ambulance in delivering palliative care within the community. The coordinator has been successful in implementing the Authorised Palliative Care Plan (APCP), which provides NSW Ambulance paramedics a treatment plan developed by the medical practitioner in consultation with the patient or their enduring guardian. This plan pre-authorises and supports the paramedic to respond to the patient’s end-of-life wishes beyond NSW Ambulance protocols, rather than transporting the patient directly to the nearest ED.
To better serve the dying wishes of Australians and help reduce the congestion of ED’s, initiatives like those of SAAS and NSW Ambulance ought to be adopted Australia-wide. Further, palliative care must become a compulsory unit of education for all undergraduate health degrees (including paramedicine), as highlighted in recent hearings from the Royal Commission into Aged Care Quality and Safety. Finally, all Australian ambulance services need to include palliative care specific CPGs within their scope of practice.
References
- Australian Institute of Health Welfare (AIHW) Palliative care services in Australia [Internet]. Canberra: AIHW; 2017.
- Swerissen H, Duckett S. Dying well [Internet]. Carlton (AU): Grattan Institute; 2014 [cited 2019 Oct. 28].
- Kirk A, Crompton P, Jack B, Knighting K, Kirt, J. A scoping exercise to explore the current perceptions and attitudes of UK paramedics towards their role in the management of End of Life Care patients, in the pre-hospital setting. BMJ Support Palliat Care. 2014 Mar 1;4(Suppl 1):7.
Madeleine Juhrmann BPSci MPH, Policy Officer, HammondCare