The thoughts and opinions of advanced life support providers in the South African private emergency medical services sector concerning pre-hospital palliative care
The World Health Organisation (WHO) defines palliative care as 'an approach that improves the quality of life of patients and their families facing the problem associated with life-threatening illness, through the prevention and relief of suffering by means of early identification and impeccable assessment and treatment of pain and other problems, physical, psychosocial and spiritual.' 1 This includes a wide variety of situations such as chronic illness and end-of-life care. 2 Palliative care is usually performed in-hospital. However, emergency medical services (EMS) often encounter patients requiring palliative care as these patients may have acute exacerbations of illness, progress towards end-of-life or require transport to a medical facility. 3-9 Thus, there is a role for palliative care in the pre-hospital setting. EMS providers are uniquely positioned to deliver this care in the pre-hospital setting as they are often the first point of medical contact. 10 This has great potential benefit for patient comfort, early identification and relief of suffering and earlier referral to hospice care. 10, 11 Despite this unique position there is an overall lack of guidance within EMS systems to manage palliative patients. 5, 6, 10 In the United States of America (USA), for example, only 5-6% of EMS systems have protocols for palliative care. 6, 10 In addition, there is no specific pre-hospital emergency care curricula on the subject, resulting in a lack of education and training for EMS providers. 3-5, 12, 13 This may stem from the historical focus of EMS training which primarily involves immediate measures to preserve life or limb until definitive care is reached. 11 This focus has resulted in an EMS ethos of 'saving lives.' 5, 12 Palliative care, on the other hand, is not focussed on 'saving lives', but rather the prevention and relief of suffering. 1 Therefore, palliative care may seem to conflict with emergency care, placing EMS providers in difficult situations when confronted with palliative care patients. 8, 12, 14 South Africa itself faces what has been termed a “quadruple burden of disease” due to communicable diseases such as HIV/AIDS, high maternal and paediatric mortality rates, non-communicable disease as well as injury. 15 The large number of patients suffering from these diseases and the life-limiting complications thereof, results in increased need for palliative care in the country as noted by the South African Minister of Health. 16 Access to health care for patients suffering from these diseases is a further challenge in the Sub-Saharan African setting. 17, 18, 19 In South Africa, EMS are often contacted 3 by those without access to transport to provide this service. 20 Thus, South African EMS providers may frequently encounter not only high acuity emergency patients, but many ill HIV/AIDS, cancer and other chronically ill patients requiring palliative care who are unable to access healthcare via alternative means. 21 European studies have found that approximately 3-5% of all pre-hospital calls involve palliative care situations. 2, 22, 23 With the quadruple burden of disease and limited access in the South African setting, this percentage is likely higher as these factors result in increased frequency of contact between EMS providers and patients requiring palliative care. Although EMS providers in South Africa manage palliative patients in the prehospital setting, to our knowledge, no research has been produced in the (South) African setting regarding prehospital palliative care. Outside of Africa literature has been produced but is limited. This literature review discusses paramedic perceptions of prehospital palliative care, prehospital palliative care patient management and legislation concerning prehospital palliative care. Finally, expert opinion pieces and recommendations are reviewed.
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