Palliative Care Assess, See, Treat and Refer Pathway

Traditional practice for paramedics responding to 911 calls from patients who are palliative and/or end-of-life, or their caregivers, has been to treat them as emergencies requiring transport to the hospital. However, based on research, insight from paramedics and feedback from patient and family experience, BC Emergency Health Services (BCEHS) determined that, when possible, a majority of these patients preferred to stay at home rather than go to the hospital.

Recognizing the opportunity this reality presented to adapt care models and enact a culture shift to improve patient care and satisfaction, a team at BCEHS developed the Paramedics & Palliative Care Project in 2019. The project yielded the ASTaR (Assess, See, Treat and Refer) Palliative Clinical Pathway, a specialized, multi-faceted pathway designed to provide compassionate and effective care to patients with life-limiting illnesses, ensuring comfort and quality of life during their end-of-life journey following a 911 call.

This pathway integrates a patient-centered approach, recognizing that going to the Emergency Department is no longer the only option to deliver care. The pathway focuses on symptom management, psychosocial support, and coordination of care between health care providers – for example, assessing pain needs on scene, supporting the patient/family with either the administration of own medications, or the Paramedic providing analgesia then liaising with the wider health care team such as community nursing or hospice. If community supports can’t be contacted there is a pathway to recontact the patient within 48 hours to complete a follow-up assessment by a Paramedic Specialist.

In 2018, the Framework on Palliative Care in Canada was developed, which helped pave the way for this project. The ASTaR Palliative Clinical Pathway enables paramedics to provide care in the home and determine if patients can stay there instead of being transferred to the hospital. BCEHS worked with health authorities and community care partners along with Canadian Partnership Against Cancer (CPAC) and Healthcare Excellence Canada (HEC).

Patient and family members are now pivotal in the decision making, essentially turning ‘emergency health services’ into a patient centric ‘unscheduled care service’ where the patient, family members and loved ones are actively involved in the decision-making process. The pathway formalizes many of the processes that paramedics have been carrying out for decades, providing them with tools to communicate with family, within BCEHS, and with the wider health care community in ways that didn’t previously exist.

The benefits of the program were quickly realized; it addresses palliative patients’ wishes, provides improved quality of care, and reduces hospital transport thereby freeing up paramedic crews and hospital emergency department capacity. The program was rolled into regular operations soon after commencing.

Gennifer Ryan generously shared the experience she and her husband Jim had when she called 911 to get help for his pain related to terminal lung cancer. Jim wished to be at home as long as possible, however, Gennifer needed help one day near the end of his life. She described how the paramedics calmly took control of the situation to stabilize Jim and ease his pain as well as calm Gennifer. The couple was grateful for the team, explaining that they could help them at home, honouring Jim’s wishes while providing support and connecting them with the community palliative care team.

Gennifer said, “This was one of the diamonds in the care we received. They did a really good job.” She went on to explain that their situation got even better when the palliative care team, activated by the paramedics, arrived the next day to support them until Jim needed admission to the hospital in his last days.

Thanks to this initiative, the experience for patients and their caregivers has improved immensely and all program goals are being met. In addition, the intangible benefits of dignity for those at the end of life and peace of mind for their caregivers have proven the deep impact of this program for improving quality of care.

Rhoan MacDonald, a Student Advanced Care paramedic shared, “There was an equal emphasis on keeping the family in the loop. Rather than us just going in and treating the pain with the medications and protocols we’ve been taught, we let the patient, and the family take the initiative and be in charge. That was really special to see.”