Martin believes that as the NHS becomes more stretched paramedics are taking on more roles, as particularly at weekends or out of hours there can be limited services available for patients. The most important thing in his eyes is ensuring that there is forward care planning in place so there is no ambiguity around care especially in an emergency. Even when paramedics engage with the GP out of hours service it’s not the same as liaising with the patient’s own GP because there isn’t that continuity of care. Often it has been proven that without care planning being in place, patients can very often be admitted to hospital inappropriately or receive inappropriate care.

There is a great need to involve the families of patients with the care plan as well. “The patient is key to the planning because everything revolves around the patient, but it is important to involve families as well. As an example, if the patient loses mental capacity and isn't able to make decisions for themselves, then if there is no official lasting power of attorney or close family members, we have to rely on substitute decision makers. This could include carers or other relatives, they then become a key part of that decision making team.”

It is important for people to look to the future and think of a plan for their eventual care as the end-of-life approaches. A lot of individuals look at this as an unnecessary exercise as they are in good health, but situations can change in a second.

There are situations when an individual is nearing the end-of-life which can be used constructively. Martin told us that “sometimes time waiting for a phone call from an out of hours GP can be used to educate family members. It can allow them into the process of preparing for end-of-life care and help them to become involved. Death is a taboo subject, particularly in the UK but you need to have these conversations sometimes. You sometimes need to make people aware their relative may actually be starting that dying process. Recognised research has shown that the earlier you can have these conversations, the better the eventual outcome is. That doesn’t mean a care plan has to be fixed, it can be adapted as the patient’s wishes change or the situation develops.”

Sometimes despite an individual’s desires to stay at home for end-of-life care the situation may change and this can become unachievable. That is why having early discussions to put a flexible care plan in place is so important. Families must be involved in these discussions. “We see quite regularly the patients have accepted their situation, they know that they're going to die sooner rather than later. Family members can be very reluctant to accept that diagnosis, the fact that in this day and age that nothing more can be done to prolong somebody's life. This is why it’s very important to engage with the family as well to assist in the process.”

Internal discussions must also be forthcoming to achieve the best result for the patient. End-of-life care is very much a multidisciplinary team approach to care as there are so many different elements of the patient’s care that must be addressed. It is vital that holistic all-around care is given by all members of the team. 

“If there is a plan in place, then we as paramedics are able to administer the ‘just in case’ medications, as long as they’ve been prescribed by the doctor. We would normally make a call to the patient’s GP or the out of hours GP just to ascertain whether it's appropriate for us to give them medications. If everything is correct we can give the medications to make the patient more comfortable, to ease their respiratory distress, or if they are having secretions towards the end of life we can administer medication to help reduce this. The combination of medications can make the patient more comfortable. This is the ideal situation really, as long as they are in a comfortable and familiar setting they wish to be in with loved ones around them, that’s the ideal end-of-life situation.”

End-of-life care is an essential part of paramedic training and there are relatively new guidelines for palliative and end-of-life care. There are currently some Palliative Care Paramedics active in South Wales who are embedded with the specialist palliative care teams to carry out the full range of activities of the nurses on the team. They will be involved with care planning, discharge planning, during the initial patient assessments, and with the patients throughout their care, to provide symptom management.

 No two cases are the same when end-of-life care is involved. “Every patient, every person, and every illness has a different trajectory towards the end-of-life, and it can be very difficult to determine when people get to that point. There are certain little pointers that you may look out for, a reduction in diet, general reduction in function, mental state deterioration but even those are not a definitive way of assessing whether somebody's approaching death.”

Martin spoke to us with passion about how he enjoys and feels great reward in his work. There are pressures at times, “With end-of-life care, you don't get another chance to do it. I think that's the pressure I feel as a paramedic, when I go to these patients, I'm very much aware that we're not going to get this opportunity to do it right again, so we need to try and make sure that we do what we can to make the patient comfortable.”

Often there can be tough times for paramedics as they realise a situation they have arrived at is going to be the end of somebody’s life. Situations can also seem severe and have very different outcomes from what is expected, nothing is 100% predictable. “I’ve seen any number of times where a patient is supposedly at the end-of-life, and you think that they are going to die imminently, and they don't, they just seem to pick up and carry on. It's a very difficult thing to try and predict when somebody's at the end of their life. From my point of view, when there is a lack of care planning it muddies the waters even further, because you’re trying to make the decision as to ‘is this person at that stage yet where they need things implemented? Or is this just a minor hiccup, and they're going to recover from it?’ Rare diseases can add another layer of complexity because you don't necessarily understand the illness.”

The importance of planning for end-of-life care will likely continue to grow in the coming years. “We have an increasingly elderly population. I think as modern medicine improves, even if we're not able to treat patients, I think we're identifying illnesses in a far better way. We're identifying more illness and there are figures to suggest that by 2030, annual deaths are going to increase by around 17%. The end-of-life care planning becomes even more important as time moves on, because we're going to be dealing with more end-of-life patients. People are living longer and we can’t take everyone to hospital, we need to look at advanced care planning as a means of maintaining people's quality of life in the community, rather than admitting them to a hospital.”

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