Ambulance staff are responding to the needs of dying patients by taking them to hospital because of a lack of alternative community-based forms of care and limited access to patient information, according to a paper published in Palliative Medicine. The study, a sociological analysis of the experiences of ambulance staff attending to patients close to the end of life, was carried out by researchers at the Cambridge Palliative and End of Life Care Group.
Dr Sarah Hoare, who led the research, carried out an in-depth look at the decision-making of a small number of ambulance staff. The study brings to life the dilemmas that ambulance staff face and shows how they made sense of the situations they encountered. Six ambulance staff were interviewed together with other healthcare staff about their involvement in hospital admissions of patients close to the end of life.
Three important factors that emerged from Dr Hoare’s analysis of the interviews were the limited availability and accessibility of care and support for dying people and their families outside hospitals, the limited information ambulance staff had about the patient and their condition, and a perceived ambulance service emphasis on hospital care.
The struggle to access help from other healthcare providers was particularly acute when help was needed ‘out of hours’ – at night and at weekends – when alternative services were unavailable or had limited capacity:
So I’ve been out to people that have had emphysema and they’re right at the end of their last legs, Who do you get to come out and support the family in those last few hours of life?”
Ambulance interviewees assessed patients – including deciding whether they were close to the end of life – from their condition when examined, often without any patient data or information. This made evaluating the clinical suitability of hospital care difficult, and where it was unclear, ambulance interviewees tended to instigate transfer to hospital to mitigate the risk of a patient missing out on life-saving care.
One interviewee explained: “I think it’s a harder decision to leave someone who’s dying at home than it is to take them in because you’re never going to get it wrong taking them in […]. It probably is wrong but it’s not wrong as in black and white if that makes sense.”
Ambulance staff said that if advance care planning documentation was seen, a patient close to the end of life was potentially eligible for home-based care packages that ambulance interviewees could theoretically help to initiate. But admission was often seen as unavoidable:
There are times when it’s just unavoidable to take people into a hospital and I think in this case there was no option, we couldn’t leave [them] at home really, [they were] in a rather, well a very unsuitable environment, [their] family obviously weren’t coping and [they were] soiled, the bed was absolutely soaked, [they were] in a tiny room, totally inappropriate for [their] needs.”
This research is part of a larger study co-supervised by Dr Stephen Barclay and Professor Mike Kelly, exploring hospital admissions close to the end of life. These hospital admissions are typically negatively portrayed in healthcare policy as preventable and avoidable, and contrary to patient preferences. The accounts of ambulance staff demonstrate that these claims are not helpful for understanding why end-of-life patients are admitted to hospital.
Hospital care was important for ambulance interviewees because it met the care needs of patients without complex negotiation with other healthcare providers, which staff recognised to be difficult and often not feasible.”
– Dr Sarah Hoare, Research Associate, Cambridge Palliative and End of Life Care Group
“Our research shows that for ambulance staff, discussions about the relative appropriateness of hospital admission for patients can seem irrelevant, because hospital was often recognised to be the only place ambulance interviewees could have sought care for patients,” said Dr Hoare.
In end-of-life care policy, ambulance staff have often been given a relatively minor role. This study identifies the critical but difficult role ambulance staff have in end-of-life admissions, though the small number of interviewees means further research is needed to assess the scope of the difficulties and how they may be addressed.
The paper presents independent research part funded by the National Institute for Health Research Collaborations for Leadership in Applied Health Research and Care (NIHR CLAHRC) Cambridge and Peterborough, and NIHR CLAHRC East of England. The writing of the paper was funded by the NIHR School for Primary Care Research (NIHR SPCR). The views expressed are those of the authors and not necessarily those of the NHS, the NIHR or the Department of Health and Social Care. The Marie Curie Design to Care programme is a service improvement programme. This research forms part of the Design phase of this programme, which is funded by Marie Curie, the UK’s leading charity caring for people living with any terminal illness and their families.
About the Cambridge Palliative and End of Life Care Group
About Dr Sarah Hoare
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