Paramedics are often called for emergency medical issues for people with life-limiting conditions.  Access to, and availability of, comprehensive palliative care can be difficult, particularly in remote and rural areas of the province.  When sudden changes occur, families can feel afraid or unsure how to support their loved one, and often believe they have few options other than to call 9-1-1.  Paramedics provide a rapid response to medical emergencies, but traditionally assess, treat and transport patients to hospital emergency rooms.  For individuals in palliative care at home and their families, the transportation of the patient to an emergency department should be the exception rather than the rule.  The person’s wishes are usually to die at home; this should be confirmed at the time of interventions with the patient, family, or palliative care team.

Paramedics providing palliative care should practice “relationship-based care” by adopting a humble, self-reflective clinical practice, and positioning themselves as a respectful and curious partner when providing care.  In particular, paramedics should seek to respect and learn about Indigenous (First Nations, Métis and Inuit) and different cultural approaches to palliative care, while reflecting on their own values and beliefs.  Acknowledging the differences and the effect a paramedics’ values and beliefs can have on others is an important step towards cultural humility.

• The purpose of the palliative care clinical practice guidelines is to provide paramedics with guidance in managing symptoms for people who are currently undergoing palliative care or end of life experience, and who  call 911 due to new or escalating symptoms.  These symptoms are most likely to be nausea and vomiting, pain, delirium or agitation, or dyspnea.  Family members may also react to severe distress by calling 911 because they experience spiritual or emotional crisis from their loved one’s suffering or changing status.
• Subcutaneous administration of drugs is most commonly used in the palliative patient population
• Drug and non-drug therapies are equally important
• Palliative care is an approach that aims to reduce suffering and improve the quality of life for people who are living with life-limiting illness
• The intent of this care is to provide relief from distressing symptoms, not the treatment of any underlying disease process
• Palliative care patients are sometimes transported to hospital by ambulance when they would have preferred to remain in their own home.  The aim of the palliative care pathway is to ensure that palliative care patients receive the most appropriate care for their condition and remain in their own home as per their wishes, when appropriate.
• Patients approaching end of life may experience pain or other symptoms that cause severe distress.  These symptoms are usually managed very well by appropriate interventions and medications administered by the primary care, community health, specialty palliative care teams, and sometimes by family members.
• Patients who are beneficiaries of the BC Palliative Care Benefits Program have a life expectancy of up to 6 months
• Hospices services are available in many communities and can serve to offer additional services to people and their families

• Consult with patients’ usual care team for the creation of a collaborative symptom management plan.  If the patients’ usual care team is not available, contact the After Hours Palliative Nursing Service (AHPNS).  If neither is available or the patient is not under a care team, contact CliniCall (1-(833)-829-4099 or 604 829-4099) for the creation of a collaborative symptom treatment plan.
• Where the patient has not followed their symptom management plan, paramedics may encourage the patient/carer to administer any medications recommended as part of that plan, prior to management under this guideline.  Paramedics can only administer the patient’s own medications where the symptom management plan is clear and they are trained and experienced in the technique of administration, and where such administration is within the scope of practice for their license.  Paramedics should not use in situ subcutaneous access devices unless they are educated in their use.
• A patient may be recognized as a palliative patient or at end of life by one or more of the following:
  • Person is diagnosed with a life limiting illness
  • Care is currently focused on comfort and symptom management rather than curative interventions
  • Person presents with Goals of Care Designation consistent with treatment in place
  • Person is under care of a physician and/or home care providing palliative care services

All palliative/end of life patients can be considered for inclusion with the BCEHS Palliative Clinical Pathway (treat and refer) approach to care. 

Refer to the Palliative Clinical Pathway for a complete explanation

• If there is a medication directive for the patient, signed by his/her GP, in the home and the medications prescribed for the required symptoms are available, consider supporting the family in the administration of the medication prescribed for that symptom as per the directive, in accordance with BCEHS policy and license scope of practice.
• If there is no medication directive for the patient in the home:
  • Contact the patient’s palliative care team (if available) and identify a collaborative care plan
  • If neither the patient’s usual care team nor the After Hours Palliative Nursing Service is available, Contact CliniCall/EPOS for the creation of a collaborative symptom treatment plan.  Follow the appropriate BCEHS palliative care CPG to manage the symptom.
  • Consider transport to ED if the symptoms cannot be managed at home and this is the expressed preference of the individual and family
• Give appropriate support to the family members present
• Recognize when patients are entering the final stages of life
• Reassess the patient to ensure the patients’ needs are met and treatment provided meets goals of care
• Complete an ePCR and ensure documentation follows the palliative clinical pathway requirements
• If patient goals of care are available, ensure a photo of the document (advanced care plan, do not resuscitate instruction, medical order for scopes of treatment, goals of care) is uploaded to the ePCR

1. Alberta Health Services. AHS Medical Control Protocols. 2020. [Link] 
2. Ambulance Victoria. Clinical Practice Guidelines: Ambulance and MICA Paramedics. 2018. [Link] 
3. BC Centre for Palliative Care. B.C. Inter-Professional Palliative Symptom Management Guidelines. 2017. [Link] 
4. Nova Scotia Health Authority. Nova Scotia Palliative Care Competency Framework. 2017. [Link] 
5. Pallium Canada. Learning Essentials Approach to Palliative Care. 2019. [Link]