EMS was designed to treat and transport acutely ill patients. However, paramedics often find themselves caring for patients for whom this approach may not be best: those enrolled in hospice.
“Transport to the ED may not be in the best interest of a patient’s expressed goals of care,” says Mike Taigman, MA, an assistant professor in the Masters in Healthcare Administration and Interprofessional Leadership Program at the University of California, San Francisco.
Patients in hospice care were routinely arriving by ambulance at several EDs in Ventura County, CA. It was happening because well-meaning family members called 911. Hospice providers expressed frustration about the transports. “This results in unnecessary suffering and can disrupt their hospice insurance coverage,” Taigman says.
Paramedics are obligated to honor documented, expressed wishes of patients or their surrogate decision-makers. However, in hospitals, there often are more time and resources to clarify goals of care. The same luxury does not exist in the prehospital setting. “Often, the documentation is not visible at the patient’s bedside,” Taigman says.
There was a clear need to provide paramedics with the skills to better communicate and care for hospice patients and their families. To address this, clinicians implemented a Mobile Integrated Hospice Healthcare (MIHH) program project in 2015 in Ventura County. Paramedic supervisors were given 30 hours of hospice training, with a focus on crisis counseling, grief, and palliative care. When EMS responded to a 911 call and determined a patient was in hospice, they contacted trained MIHH staff.
During the three-year study period, 523 hospice patients were cared for by MIHH.1 The percentage of hospice patients transported to the ED was 36% in the first year, 33% in the second year, and 24% in the third year. This was compared to 80% of hospice patients transported, on average, during the six months before project implementation.
“Several paramedics, after months or years of observing the specially trained MIHH paramedics, stated that they now felt more comfortable communicating with hospice patients,” says Amelia Breyre, MD, the study’s lead author.
Many paramedics now contact hospice nurses independently. “More needs to be done to include, recognize, and encourage EMS providers and the compassionate care they can give,” Taigman says.
It is important to note that caring for hospice patients is just one of the ethical challenges paramedics face. While caring for patients, it is common for EMS to find illegal drugs. “If law enforcement is on the scene, paramedics must decide whether to let the police know what they have found or quietly dispose of the drugs,” Taigman notes.
Paramedics also are mandatory reporters for child abuse and are regularly faced with situations that could be abuse but are not clearly abuse. “EMS has to decide whether to report a vague suspicion,” Taigman says.
Paramedics also encounter teenage girls with abdominal pain who report they are sexually active, but ask EMS not to tell their parents. In the hospital, “bioethicists should be mindful of the spectrum of healthcare providers that exist beyond the hospital setting,” Breyre says.
In terms of transporting hospice patients, ethicists should be aware of any protocols that are in place. These may include specific provisions about palliative care, hospice, or grief counseling. Breyre says these are two important questions for ethicists to ask: Is there education to give EMS providers communication skills and better understanding of hospice? How can EMS protocols be improved to support both paramedics and patient care?
It also is important for clinicians to involve patients and families proactively. “It is helpful to make sure families are prepared with a clear understanding of the role of hospice — and when they should and should not call 911,” Breyre says.
- Breyre A, Taigman M, Salvucci A, Sporer K. Effect of a mobile integrated hospice healthcare program on emergency medical services transport to the emergency department. Prehosp Emerg Care 2021;March 30:1-8.