Project overview
This study has been funded by Marie Curie Research Grants Scheme (MC-21-802).
Purpose:
The research will describe, characterise and evaluate paramedic delivered end-of-life service provision to answer the research question: how do different models of service provision shape paramedic practice and influence experiences and outcomes for individuals at end-of-life? The evaluation will enable service delivery models, their features, and effective risk management by paramedics to be distinguished to facilitate sharing of best practice and improve the quality of care and support for people at end-of-life.
Background:
Paramedics are frequently and increasingly called to patients at end-of-life (Murphy-Jones et al 2021, Myall et al 2020). Such unscheduled care, whether in or out-of-hours, often occurs in the situation when family or friends are fearful and/or exhausted, perceiving their only option is to call 999. In Scotland, analysis of unscheduled NHS services found 77% of end-of-life patients living at home phoned the ambulance service in the last year of life and those living in the most deprived areas accessed help from the ambulance service most often (Mason et al 2020). It can be hypothesized that calls to 999 are more likely to lead to unplanned hospital admissions, increased hospital costs, and potentially hospital deaths (deaths not in the preferred place of care).
Paramedic involvement at end-of-life is anticipated to increase with an ageing population. This is also complicated by increasing pressure on community-based services. However, paramedics' role and scope in this context is unclear (Lord et al 2019) as is the associated quality of paramedic delivered end-of-life care provided to those living with terminal illness and their families. Education about end-of-life care is lacking in paramedic training (Murphy-Jones et al 2021), and instead focuses on preserving life and promoting recovery, diametrically opposed to end-of-life care (Grady 2014).
In recognition of the increasing scope of paramedic practice in this area new and innovative models of paramedic delivered service provision at end-of-life have emerged. These include Macmillan funded palliative care specialist multi-disciplinary teams (Murphy-Jones et al 2021, Turnbull 2020), as well as specialist paramedics and advanced paramedic prescribers working in this area. It is important that different models are evaluated, alongside usual service delivery, to ascertain the potential of these to increase the quality and contribution of paramedics to the field of end-of-life care.
Most paramedic service provision is provided out-of-hours, as this accounts for two-thirds of the week (6.30pm - 8am Monday to Friday, and weekends) (Williams et al 2019). Out-of-hours service provision is problematic at end-of-life (e.g. Brettell et al 2018, Mason et al 2020, Papavasiliou et al 2021). Evidence from a recent systematic review demonstrates out-of-hours providers face complex challenges mitigating against the delivery of high quality care. Only one of the 25 included studies was specific to ambulance staff, but the review highlighted general complexities: access to patient information, meeting needs of those imminently dying, lack of confidence in providing end-of-life care, uncertainties about prognostication, and decisions about whether the patient’s condition is potentially reversible with hospital treatment or if they are best remaining at home with symptomatic relief (Papavasiliou et al 2021). Empirical data is lacking on the specific complexities faced by paramedics and whether these vary in and out-of-hours.
Research design:
Multi-phase mixed methods design, to evaluate paramedic delivered end-of-life service provision.
Objectives:
1. To conduct a large-scale online survey throughout England to evaluate paramedics’ current practices, factors influencing their professional contribution and the potential for the paramedic workforce to improve end-of-life care (Phase 1).
2. To characterise and evaluate models of service delivery (including innovative models) via mixed methods case studies of practice (Phase 1 + 2).
3. To conceptualise decision-making and risk management by paramedics on scene using vignette methodology within interviews (Phase 2).
4. To hold an expert consultation workshop to consider findings and generate paramedic service delivery recommendations to support end-of-life care (Phase 3).
Methods:
A scoping review of the literature to inform the Phase 1 questionnaire design; England-wide survey via online questionnaire (Phase 1); in-depth case studies of service delivery models (3 cases), using case record analysis, and qualitative interviews with patients, family caregivers and service providers (Phase 2); and expert consultation workshop to co-produce service delivery recommendations (Phase 3).
Purpose:
The research will describe, characterise and evaluate paramedic delivered end-of-life service provision to answer the research question: how do different models of service provision shape paramedic practice and influence experiences and outcomes for individuals at end-of-life? The evaluation will enable service delivery models, their features, and effective risk management by paramedics to be distinguished to facilitate sharing of best practice and improve the quality of care and support for people at end-of-life.
Background:
Paramedics are frequently and increasingly called to patients at end-of-life (Murphy-Jones et al 2021, Myall et al 2020). Such unscheduled care, whether in or out-of-hours, often occurs in the situation when family or friends are fearful and/or exhausted, perceiving their only option is to call 999. In Scotland, analysis of unscheduled NHS services found 77% of end-of-life patients living at home phoned the ambulance service in the last year of life and those living in the most deprived areas accessed help from the ambulance service most often (Mason et al 2020). It can be hypothesized that calls to 999 are more likely to lead to unplanned hospital admissions, increased hospital costs, and potentially hospital deaths (deaths not in the preferred place of care).
Paramedic involvement at end-of-life is anticipated to increase with an ageing population. This is also complicated by increasing pressure on community-based services. However, paramedics' role and scope in this context is unclear (Lord et al 2019) as is the associated quality of paramedic delivered end-of-life care provided to those living with terminal illness and their families. Education about end-of-life care is lacking in paramedic training (Murphy-Jones et al 2021), and instead focuses on preserving life and promoting recovery, diametrically opposed to end-of-life care (Grady 2014).
In recognition of the increasing scope of paramedic practice in this area new and innovative models of paramedic delivered service provision at end-of-life have emerged. These include Macmillan funded palliative care specialist multi-disciplinary teams (Murphy-Jones et al 2021, Turnbull 2020), as well as specialist paramedics and advanced paramedic prescribers working in this area. It is important that different models are evaluated, alongside usual service delivery, to ascertain the potential of these to increase the quality and contribution of paramedics to the field of end-of-life care.
Most paramedic service provision is provided out-of-hours, as this accounts for two-thirds of the week (6.30pm - 8am Monday to Friday, and weekends) (Williams et al 2019). Out-of-hours service provision is problematic at end-of-life (e.g. Brettell et al 2018, Mason et al 2020, Papavasiliou et al 2021). Evidence from a recent systematic review demonstrates out-of-hours providers face complex challenges mitigating against the delivery of high quality care. Only one of the 25 included studies was specific to ambulance staff, but the review highlighted general complexities: access to patient information, meeting needs of those imminently dying, lack of confidence in providing end-of-life care, uncertainties about prognostication, and decisions about whether the patient’s condition is potentially reversible with hospital treatment or if they are best remaining at home with symptomatic relief (Papavasiliou et al 2021). Empirical data is lacking on the specific complexities faced by paramedics and whether these vary in and out-of-hours.
Research design:
Multi-phase mixed methods design, to evaluate paramedic delivered end-of-life service provision.
Objectives:
1. To conduct a large-scale online survey throughout England to evaluate paramedics’ current practices, factors influencing their professional contribution and the potential for the paramedic workforce to improve end-of-life care (Phase 1).
2. To characterise and evaluate models of service delivery (including innovative models) via mixed methods case studies of practice (Phase 1 + 2).
3. To conceptualise decision-making and risk management by paramedics on scene using vignette methodology within interviews (Phase 2).
4. To hold an expert consultation workshop to consider findings and generate paramedic service delivery recommendations to support end-of-life care (Phase 3).
Methods:
A scoping review of the literature to inform the Phase 1 questionnaire design; England-wide survey via online questionnaire (Phase 1); in-depth case studies of service delivery models (3 cases), using case record analysis, and qualitative interviews with patients, family caregivers and service providers (Phase 2); and expert consultation workshop to co-produce service delivery recommendations (Phase 3).
