INTEGRATION OF PALLIATIVE CARE IN THE PREHOSPITAL SETTING

DAVID WILLISCROFT/JENNIE

HELMEROCTOBER 7, 2019

Prehospital Palliative Care

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DISCLOSURES

FACILITATOR FOR PALLIUM

LEAP PARAMEDIC

Is Palliative Care everywhere?

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Prehospital Palliative Care

• stems from increasing palliative needs in community

• calls are often in response to symptom needs, acute changes

• can result in uncomfortable stays/treatments in the ED.

• may help avoid death in hospital

Outline• Case• History• BC Experience• Future Directions• Questions...AND IDEAS!

50 M Met HCC• Massive UGIB at home• Wife RN• Acute dyspnea, distress++• EHS called• Does not want to be transferred

to hospital• Home DNR in place

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@ house• Massive hematemesis and melena• Cachectic/jaundiced patient• Drowsy, GCS 13-14, RR 35, moaning• Wife distressed over patient's pain,

dyspnea, and explosive bleeding• Adamant no transfer to hospital• Home DNR/Expected Death at Home

Document

Are

paramedics

equipped to

deal with this

at home?

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Emergency Room Experience

• Often patients/families don't want to be there

• ER teams are not set up well for end of life care (despite more training)

• QI Rounds are full of cases of patients being transferred to die

• Distressing experience for both staff and caregivers

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Why is the ER Bad?• Loud• No privacy• Lack of information/relationship• No space• Uncomfortable• Discomfort w/ patients with

palliative needs• Triage bias

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ED Improvements

• Better training of residents

• More awareness of Palliative

Care in ED

• EMR-better information faster

• More Palliative Care presence

in the ED

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HOW DO WE MEET THE NEEDS OF THE PUBLIC?

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PARAMEDICS AND PALLIATIVE CARE

PROJECT

YOUR PROVINCIAL PREHOSPITAL

RESOURCE

o 3,600+ Paramedics &

Dispatchers

o >500,000 9-1-1 calls per

year

o 3 dispatch operations

centres

o 188 stations

BCEHS ACTION PLAN

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Ensure the right care is

provided to the right patient

with the right resource at

the right time

TRANSFORMATION-SETTING THE TABLE

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o Ministerial Orders:

• Secondary Triage

• Community Paramedicine

• Clinical Pathways with non-

conveyance

o Culture Shift…not mandated,

but occurring

PARAMEDICS & PALLIATIVE CARE

PROJECT

17

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o Treat patients in line with

their wishes/goals of care

o Increased patient

satisfaction with place of

death

o Reduce ED conveyance

OBJECTIVES

INCLUSION CRITERIA

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• Have an advanced life-

limiting illness, or

• Care is currently focused on

comfort and symptom

management, rather than

curative interventions and

• Presenting symptoms are

considered related to the

patients’ palliative

condition

2500 PATIENTS WITH PALLIATIVE DIAGNOSIS

ACCESSED 9112016/17 (CIHI)

40% 45% 50% 55%

Metro Van

Rest of BC

Location

Time of Day

Day of Week

HOSPITAL DISPOSITION OF PATIENTS W/ A PALLIATIVE DIAGNOSIS TRANSPORTED

63%

16%

21%

2500 Palliative/EOL Patients Transported

Died

Discharged

Transferred

CIHI 2016/2017

Died in Hospital

GOALS OF CARE AVAILABILITY

0% 10% 20% 30% 40% 50% 60%

Written

In Progress

Verbal

None

Narrative ePCR

PALLIATIVE CLINICAL PATHWAY

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Determine appropriate dispatch procedure

AssessInclusion Criteria

Treat Refer

Case Conclusion• Portable suction for patient's mouth• SC Midazolam 5 mg• SC Fentanyl 25 mcg PRN q 10 min w

good effect• Patient changed, positioned comfortably

with dark towels on bed• Dies comfortably about 45 min after

EHS arrival

EHS Med Availability

• Midazolam• Ketamine• Fentanyl• Dimenhydrinate

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EHS Meds Not Available (yet)

• Haloperidol• Methotrimeprazine

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Issues to work on

• Communication with Primary Team-how does this happen?

• EPOS training?• Sensible broadening of

medication availability to EHS• Expanding roll out of LEAP

Paramedic

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THANK YOU