Widening the conversation: Paramedic involvement in interprofessional care

In this special issue of Progress in Palliative Care we explore the nexus between palliative care and paramedicine by presenting important initiatives being undertaken in Australia, New Zealand, the United Kingdom, and Canada to improve access to care. In each of the settings described, paramedics are regulated or registered health care professionals working in health settings that include ambulance or emergency medical services. Paramedics within these regions can be rapidly deployed to provide urgent health care to the entire population of the areas they serve, including areas that are not served by out of hours specialist palliative care. We know that paramedics are involved in care for patients who may be experiencing a health crisis related to a life-limiting condition, and that the call to the emergency service may arise from distressing symptoms such as pain, agitation, respiratory distress, and nausea. Although paramedics can provide symptom relief, paramedic practice has traditionally focussed on the assessment and management of acute injury and illness rather than chronic illness and the care of patients and their carers, particularly at end of life. Previous research found that paramedics perceived that limited exposure to palliative education, lack of practice guidelines that address the needs of palliative care patients, and limited referral options and 24-hour access to specialist advice inhibit their ability to provide safe and effective care for patients in their home, particularly at the end of life. 1 In countries such as Australia, these barriers to care in the community result in most calls relating to a palliative crisis being transferred by ambulance to an emergency department. 2 The contributions to this special issue describe initiatives that involve paramedics and ambulance services planning for care that may include a broader range of management options than the default option of transport to a hospital. It is recognised that patients may experience illness or injury that is unrelated to their palliative condition, and that health emergencies associated with a life-limiting illness may require hospital admission. However, where the patient expresses a preference for care at home or has an advance care directive that describes this preference, every opportunity should be explored to pursue the universal maxim of person-centred care. In order to achieve this Carter and colleagues present the outcome of a national collaborative initiative in Canada that aims to support paramedics in the provision of care in the home, and develop mechanisms to share patient goals of care with other members of the multi-disciplinary healthcare team to ensure that the patient’s wishes are respected. Murphy-Jones and colleagues describe two case reports of UK ambulance service improvement programmes that involved collaboration with a specialist palliative care service to support paramedics and identify appropriate alternatives to hospital conveyance. They discuss the need to educate paramedics in palliative care and examine the development of specialist paramedic roles in end-of-life care. Care pathways are the focus of a report by Helmer and colleagues, who describe the development of a new clinical pathway that aims to improve patientoriented care by enabling paramedics to provide care for patients in their own home, potentially reducing the requirement for transfer to an emergency department. Conversations about the need for advance care directives are often difficult to initiate, and as such, Goodwin et al. sought to identify paramedics’ views on their involvement in proactive identification of patients in their final stage of life and the initiation of conversations regarding advance care planning in the United Kingdom. Both Anderson and Cameron, together with their colleagues, remind us that paramedics are often present at the time of death of a patient and that support of carers and family members at this time is a vital professional responsibility, yet paramedics may not be well supported or prepared for this role. This may include decisions to withhold or withdraw resuscitation. These reports recommend engagement