Do we or don t we? Ambulance crews and emergency calls at the end of life.

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1 Do we or don t we? Ambulance crews and emergency calls at the end of life. Dan Munday Associate Clinical Professor/ Honorary Consultant in Palliative Medicine

2 Development of End of Life Care for Paramedic Practitioners Coventry University Project Lead - Annie Pettifer University of Warwick Research team Dan Munday, Sandeep Gakhal, Rosie Bronnert West Midlands Ambulance Service - Rob Cole, Julian Rhodes Myton Hospice - Peter Stuart NHS West Midlands - Funder

3 Context Ambulance crews often attend patients at the end of life Patients deteriorates should they be admitted to hospital? Cardiac arrest should they be resuscitated? Default position Must transport patient unless they refuse except in certain circumstances (e.g. epileptic fitting) Must give CPR unless there is a valid DNAR order (unless patient is terminally ill being transported to a hospice). DNAR (Resuscitation Council 2007, JRCALC guidelines) Most senior clinician takes responsibility for decision (doctor or nurse) No regulation for DNAR form could be verbal in emergency

4 End of Life Care and Ambulance Crews Anecdotal concern that patients are treated suboptimally Resuscitation attempts tried on patients who have died Patients admitted and die in A/E Paucity of literature Systematic Review (Seeley and Munday, 2011)

5 Overall Project Development of End of Life Care for Paramedic Practitioners Research Warwick Medical School Online education programme Coventry University Systematic Literature Review Questionnaire Study Interview study

6 Overall Project Development of End of Life Care for Paramedic Practitioners Research Warwick Medical School Online education programme Coventry University Systematic Literature Review Questionnaire Study Interview study

7 Aims 1. To gain an understanding of the practice & experiences of ambulance clinicians when they encounter patients who they perceive to be at the end of life 2. To understand what influences the decisions they make 3. To explore their previous education in end of life care and their wishes for further training. 4. To inform an online training programme

8 Method Questionnaire Interviews 200 ambulance personnel 10 stations throughout West Midlands Distributed by station manager 10 questionnaire responders Purposive sample Telephone interviews Semi-structured and in depth Transcribed verbatim Analysed thematically

9 Questionnaire Results Respondents

10 Respondents - Grade 107/200 (54%) responded Grade Emergency Care Practitioner 5 (5%) Paramedic 85 (80%) Emergency Technician 14 (13%) Emergency Care Assistant 2 (2%)

11 Basic Qualification Qualification IHCD Training 78 (73%) University 16 (15%) IHCD and University 9 ( 8%) Other 4 ( 4%)

12 What type of EoLC training have you received? Training Yes No EoLC Management 29 (28%) 76 (71%) DNAR Orders 43 (40%) 63 (59%) Read WMAS DNAR policy 60 (56%) 46 (43%)

13 Frequency of End of Life Care Work

14 How often are you called to a terminally ill patient cancer/ non cancer? Number of patients Frequency 1 per shift or more 40 (37%) 1 per 2-5 shifts 29 (27%) 1 per 6-10 shifts 16 (15%) 1 per shifts 13 (12%) Less than 1 per 20 shifts 9 ( 8%)

15 How often do you attend a cardiac arrest in a terminally ill patient? Number of Patients Frequency 1 per 2-5 shifts 3 (3%) 1 per 6-10 shifts 4 (4%) 1 per shifts 28 (26%) Less than 1 per 20 shifts 72 (67%)

16 DNAR Orders Experiences and Views

17 How frequently does a terminally ill patient who arrests have a DNAR order? Number of patients Frequency Never 10 (9%) Less than 1 per (36%) 1 per (21%) 1 per (18%) 1 per (8%) More than 1 per 5 5 (5%)

18 Is the DNAR valid? Type of DNAR YES Written on hospital headed notepaper by a consultant 80% Written on practice headed notepaper by a GP 78% Written on headed notepaper by a Macmillan nurse 27% Written on headed notepaper by a district nurse 3% Written on a standard ambulance service form by a medical practitioner 35% A verbal order at the scene by anyone able to write an order 20% A verbal order over the telephone by anyone able to write an order 8% Given to you by ambulance control 16%

19 How long CAN a DNAR order be valid? Length of validity Frequency of response 7 days 10 (9%) 14 days 18 (17%) 28 days 12 (11%) 6 months 12 (11%) No time limit 37 (35%) Other: 14 (13%)

20 How would you manage this patient?

21 You are called to attend Mr X, a 68 year old male who is fitting at home. When you arrive, you are told by a HCA that Mr X has lung cancer and brain metastases. Mr X is comfortable on oxygen. He is unconscious and is having episodes where his left arm and leg are shaking. (Otherwise stable). Whilst you are assessing Mr X, his daughter arrives. His daughter tells you that he is expected to die soon. He has fitted before and the family had known he may have further fits. She reports that Mr X has said that he does not want to be admitted to hospital in any circumstance.

22 Are you likely to transport Mr X to hospital? Very Likely/ Likely Unlikely/ Very Unlikely 67 (65%) 37 (35%) (20-39 more likely to transport than age group p=0.02)

23 His daughter then remembers that he has an advance care plan and shows it to you. It is written by Mr X and signed by him and his GP stating that he would not under any circumstances want to be admitted to hospital. Are you now likely to transport? Very Likely/ Likely Unlikely/ Very Unlikely 67 (65%) >>> 15 (14%) 37 (35%) >>> 90 (86%)

24 Interview Themes: Delivering Care: Challenges Is the patient terminal? Lack of access to help Lack of fit: policies vs what is morally right Worries re being disciplined for wrong decision

25 "it s not too bad during the week because there are people that you can ring and get advice from. Weekends are just awful. (Participant 92) with our protocol we had to take the lady to hospital and try and resuscitate her. The husband of the patient was there and he just wanted to sit and hold her hand so gently we prepared for the worse, that we were going to have to resuscitate (Participant n)

26 it s registration at the end of the day. We re so worried about, about losing it and doing the wrong thing and by resuscitating gonna be...we re fine, but it s not the best for the patient (Participant 12)

27 Delivering Care: Solutions accessing advice from other professionals support from other clinicians support from ambulance control documentation in the patients home Education Preference education from palliative care professionals Questionnaires 96% would welcome it

28 Online Education

29 End of Life Care: Decision Support Tool

30 Conclusions Ambulance crews frequently deal with patients at the end of life They have received little education They face complex competing challenges They receive little support in making decisions and default to the safe option admit and resuscitate. Training is being well received Generalist and specialist clinicians need to provide them with support e.g. DNAR, advance care planning, availability, training

31 Thank You Ken Condemns London Ambulance service cuts

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