Principles of Palliative and End of Life Care for Paramedics

Paramedics are often the first port of call for those requiring emergency medical attention and, as such, they frequently encounter patients who are receiving palliative or end of life care. But as professionals whose training focuses on how to save a life, how can they best deal with patients who are approaching the end of theirs? In this situation, paramedics often need to make the difficult decision as to whether it is appropriate to transfer their patient to hospital, a decision which can have a significant impact not only on the patient and their family, but also on the paramedic themselves. This means that it is vital for paramedics to have an understanding of palliative and end of life care. This book provides a comprehensive guide to the philosophy, ethics, symptom control, emergencies and psychosocial aspects that underpin palliative and end of life care in paramedic practice. Chapters are written by paramedics and specialists in palliative and end of life care, who have decades of experience in providing care for patients in the community. Clinical chapters feature paramedic case study scenarios, aimed at allowing the reader to think about applying theory to practice. This is the first book aimed solely at supporting paramedics in their role caring for palliative and end of life patients. Contents: 1. Death & Dying in Society 2. Defining Palliative Care 3. Palliative Care Emergencies 4. Symptom Control in Palliative Care 5. Enhanced Communication 6. Care of the Dying Patient in the Last Days of Life 7. Ethics 8. Resilience in Paramedic Practice 9. The Paramedic as a Palliative Care Specialist Palliative and End of Life Care for Paramedics 1 Title Page 2 Copyright 3 Contents 4 Disclaimer 11 Acknowledgements 12 Abbreviations and Acronyms 14 About the Authors 16 Foreword 20 Chapter 1: Death and Dying in Society 22 Introduction 22 Death in the Pre-Modern Era 22 Death in the Modern Era 24 Funeral Poverty 26 The Effect of the Biomedical Model and Death Denial on Clinical Practice 27 Clinical Language Used in Palliative and End of Life Care 27 The Biopsychosocial Model 28 Conclusion 30 References 30 Chapter 2: Defining Palliative Care 32 Introduction 32 Defining Palliative and End of Life Care 33 World Health Organization Definition and Principles of Palliative Care 33 The International Association for Hospice and Palliative Care Definition of Palliative Care 33 The Foundation of the Hospice Movement 34 UK Policies and Frameworks in Palliative and End of Life Care 36 The Liverpool Care Pathway 36 One Chance to Get It Right Document 37 End of Life Care Strategy 37 Gold Standards Framework 39 Ambitions for Palliative and End of Life Care (2015) 40 ReSPECT 40 The National Institute for Health and Care Excellence Guidelines 41 Preferred Place of Care and Advance Care Planning 42 Paramedic Practice and Palliative Care Specifics 44 What Is Already Known About the Topic? 44 References 45 Chapter 3: Palliative Care Emergencies 48 Introduction 48 Superior Vena Cava Syndrome 50 Background 50 Impact 50 Pathophysiology and Clinical Aspects 51 How Do I Recognise It? 52 Management 54 In-Hospital Treatment 56 Conclusion 57 Malignant Hypercalcaemia 58 Background 58 Impact 58 Pathophysiology 58 How Do I Recognise It? 59 Pattern Recognition 60 Management 61 In-Hospital Treatment 63 Metastatic Spinal Cord Compression 63 Background 63 Impact 65 Pathophysiology 67 How Do I Recognise It? 68 Management 72 In-Hospital Treatment 75 Holistic Care 75 Neutropenic Sepsis 75 Background 75 Impact 77 Pathophysiology 77 The 3 Rs – Recognition, Resuscitation, Referral 78 How Do I Recognise It? 79 Resuscitation and Referral 80 In-Hospital Treatment 81 Catastrophic Events in Terminal Patients 82 Background 82 Terminal Haemorrhage 82 Complete Airway Obstruction 84 Case Studies 87 References 89 Chapter 4: Symptom Management 92 Introduction 92 Pain Management 93 Pain Assessment 94 Pain Assessment in Patients with Cognitive Impairment 96 The World Health Organization (WHO) Pain Ladder 98 Opioids for Pain 98 Commonly Used Drugs 101 Pain Pathways and Sites of Action 104 Non-Pharmacological Approaches 104 Key Points 104 Nausea and Vomiting 106 Mechanisms of Vomiting 106 The Emetic Pathway – What Initiates Vomiting? 107 Nausea and Vomiting – Clinical Triggers 108 Management of Nausea and Vomiting 111 Key Points 113 Breathlessness 113 Assessment 114 Reversible Causes 114 The ‘Breathing, Thinking, Functioning’ Model 115 Managing Breathlessness – Break the Cycle 116 Pharmacological Interventions 117 Breathlessness in the Last Days of Life 118 Key Points 119 Delirium 119 Definition 119 Causes 120 Recognising Delirium 120 Hyperactive, Hypoactive and Mixed Delirium at End of Life 120 Screening for Delirium 121 Management 122 Drug Therapy 122 The Effects of Delirium on Families 123 Key Points 123 Respiratory Secretions at End of Life 123 Causes 123 Explaining to Patient’s Family 123 Management 123 Urinary Retention 124 Key Points 124 Constipation 124 Causes 124 History and Examination 125 Management 125 Key Points 126 Hiccups 127 Assessment 127 Management 127 Intractable Hiccups 128 Key Points 128 Case Studies 128 Further Reading 131 References 131 Chapter 5: Enhanced Communication Skills in Palliative and End of Life Care 136 Introduction 136 Communication with Patients, Family and Friends 137 Barriers to Communication: FEARS/FIBS 139 Patient Advocacy 141 Interprofessional Communication Skills 142 Breaking Bad News 142 Truth-Telling in Clinical Practice 143 Referrals, Documentation and Follow Up 144 Hope and Communication 144 Conclusion 145 Case Studies 146 References 148 Chapter 6: Care of the Dying Patient 150 Introduction 150 Ten Key Elements for Care of the Dying Patient 151 Recognising Death 151 Anticipatory Medication 154 Pain at End of Life 154 The Conversion of Oral Opioids to Subcutaneous Opioids 155 Key Points 156 Nausea at End of Life 156 Antiemetic Drugs at End of Life 157 Delirium and Agitation at End of Life 157 Drugs Used for Delirium at End of Life 158 Drugs Used for Agitation at End of Life 158 Respiratory Secretions and Dyspnoea at End of Life 158 Drugs Used for Respiratory Secretions at End of Life 159 The Doctrine of Double Effect 159 Do Not Attempt Cardiopulmonary Resuscitation Order (DNACPR) 160 What is a Good Death? 160 Care After Death 162 Bereavement, Grief and Loss 163 Bereavement 163 Grief and Loss 164 Do Our Own Beliefs and Views About Death Affect Our Clinical Practice? 165 Key Points 166 Case Studies 167 References 170 Chapter 7: Ethics 174 Introduction 174 Summary of the Mental Capacity Act 2005 175 Ethical Theories 177 Deontology and Utility 177 Critique of Deontology and Utility 178 Ethical Decision Making 179 Cross Cultural Values 180 Advance Directives and Advance Care Planning 183 Ethics in Practice: Best Interests, Autonomy, Consent and Capacity 187 Summary 190 References 191 Chapter 8: Professional Resilience 196 Introduction 196 Paramedic Culture Around Death 197 Conflict and the End of Life Patient 198 Palliative Care Research and ‘Getting it Right’ 200 Psychological Demands of Paramedic Practice 201 Professional Resilience 202 Detachment, Compartmentalising and Emotional Blunting 203 The Use of Humour 204 Conclusion 205 Case Studies 205 References 207 Chapter 9: The Paramedic as an End of Life Specialist 210 Introduction 210 The Extended Role of Paramedics in the Care of Palliative and Dying Patients 211 Paramedics and Clinical Decision Making at the End of Life 214 The Changing Education Requirements of Paramedics for Effective Palliative Care and the Impact of Research 217 The Way Forward for Paramedics in the Care of Palliative and End of Life Patients 219 References 220 Index 224 Paramedics are often the first port of call for those requiring emergency medical attention and therefore frequently encounter patients who are receiving palliative or end of life care. As professionals whose training focuses on saving lives, how can paramedics help patients who are approaching the end of theirs? Palliative and End of Life Care for Paramedics provides a comprehensive overview of palliative and end of life care and how it fits in with the role of the paramedic. Bringing together a range of authors, including paramedics and palliative care specialists, the book covers relevant aspects of caring for patients at the end of life. Topics include philosophy, ethics and psycho-social factors as well as how to deal with palliative care emergencies, symptom control and caring for the dying patient. It also covers enhanced communication skills and how to support relatives and loved ones along with a chapter on professional resilience as a paramedic and coping with death. Putting end of life care within the context of the paramedic role, the book also contains case study scenarios which allow the reader to apply theory to their practice. It is essential reading for all those hoping to better understand the complexities of caring for patients approaching the end of life. Paramedics are often the first port of call for those requiring emergency medical attention and therefore frequently encounter patients who are receiving palliative or end of life care. As professionals whose training focuses on saving lives, how can paramedics help patients who are approaching the end of theirs? Palliative and End of Life Care for Paramedics provides a comprehensive overview of palliative and end of life care and how it fits in with the role of the paramedic. Bringing together a range of authors, including paramedics and palliative care specialists, the book covers relevant aspects of caring for patients at the end of life. Topics include philosophy, ethics and psychosocial factors as well as how to deal with palliative care emergencies, symptom control and caring for the dying patient. It also covers enhanced communication skills and supporting relatives and loved ones along with a chapter on professional resilience as a paramedic and coping with death. Putting end of life care within the context of the paramedic role, the book also contains case study scenarios which allow the reader to apply theory to their practice. It is essential reading for all those hoping to better understand the complexities of caring for patients approaching the end of life.