Paramedics and EMRs/FRs 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 and EMRs/FRs provide a rapid response to medical emergencies, but traditionally assess, treat, and convey patients to hospital emergency rooms.  For individuals in palliative care at home with their families, conveyance 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 and EMRs 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 and EMRs 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 of personal values and beliefs one can have on others is an important step towards cultural humility.

• The purpose of the palliative care clinical practice guidelines are to provide paramedics and EMRs 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/or 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 conveyed 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.
• Hospice services are available in many communities and can serve to offer additional services to people and their families.

• Consult with the patient's usual care team for the creation of a collaborative symptom management plan.  If the patient's usual care team is not available, contact the After Hours Palliative Nursing Service (AHPNS - contact phone number varies based on location).  If neither is available or the patient is not under a care team, contact CliniCall for the creation of a collaborative symptom treatment plan.
• Where the patient has not followed their symptom management plan, paramedics and EMRs may encourage the patient or 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, 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:
  • Diagnosed with a life limiting illness
  • Care is currently focused on comfort and symptom management rather than curative interventions
  • Goals of Care Designation consistent with treatment in place
  • 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 Care Clinical Pathway (treat and refer) approach to care. EMRs are required to contact CliniCall for consultation to proceed with the ASTaR clinical pathway. 

Refer to the Palliative Care Clinical Pathway for a complete explanation

• If there is a medication directive for the patient that is signed by their GP, the patient is 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 for the creation of a collaborative symptom treatment plan.
  • Follow the appropriate BCEHS palliative care CPG to manage the symptom
  • Consider conveyance to ED if the symptoms cannot be managed at home and this is the expressed preference of the individual and family
• Provide appropriate support to the family members present.
• Recognize when patients are entering the final stages of life.
• Reassess the patient to ensure the patient's needs are met and the treatment provided meets the 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 (e.g., advanced care plan, 'do not resuscitate' instruction, medical order for scopes of treatment, goals of care) is uploaded to the ePCR.
• EMRs are required to contact CliniCall for consultation to proceed with the ASTaR clinical pathway. 

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] 

• 2022-01-06: EMRs now authorized to access ASTaR clinical pathway.