End of life care
Palliative care patients at end of life often experience acute crises due to their deteriorating health that require intervention from health care professionals. These situations are mostly foreseeable and managed through advance care planning and anticipatory prescribing for symptom control at end of life by the primary care team involved with the patient and their family. Out of Hours and Urgent Care providers need to be aware of these plans when asked to attend in a crisis situation.
This provision is in line with the NHS England palliative and end of life care strategy 2015 - 2020 Ambitions for Palliative & End of Life Care which contains the 6 Ambitions for every patient and their family that NHS services should meet. You can read more here.
Advance Care Planning: Resuscitation Decisions at End of Life
There are, however, occasions when paramedic crews are called to patients at end of life who do not have any of the abovementioned care planning in place.
This can create distressing situations for individual patients and their families particularly when discussions concerning the appropriateness of resuscitation and the completion of appropriate documentation in the form of a Treatment Escalation Plan (TEP), Do Not Resuscitate Order (DNAR) or Advance Decision to Refuse Treatment (ADRT) documents have not been completed and inappropriate resuscitation and basic life support is commenced.
The Treatment Escalation Plan (TEP), Do Not Resuscitate Order (DNAR) and Advance Decision to Refuse Treatment (ADRT) documentation play a vital role in allowing a dignified death and preventing unnecessary distress for all involved. It is vital that the original documents are kept with the patient or within their individual care records/notes and made available as soon as required. It is not sufficient for crews to be advised verbally that it is 'against the patient’s or family wishes' for resuscitation and basic life support to be started. Paramedic crews need to have sight of the original Treatment Escalation Plan (TEP) or Do Not Resuscitate Orders (DNAR) in order to make a best interest decision on behalf of the patient where they lack capacity to make the decision themselves.
Where the patient has a valid, applicable Advance Decision to Refuse Treatment (ADRT) or an appointed attorney (LPA) with authority for health and welfare decisions including section 5A again the appropriate documentation must be provided in order that paramedic crews can respect and comply with the legal requirements of the ADRT or LPA.
In all situations where a patient has capacity and is able to communicate their wishes paramedic crews will respect their capacitous decisions (wherever possible) as advance decisions e.g. Treatment Escalation Plans (TEP), Do Not Resuscitate Orders (DNAR), Advance Decisions to Refuse Treatment (ADRT) or Lasting Power of Attorney for Health & Welfare are only applicable at the time a patient loses (mental) capacity to make those decisions for themselves.
The National Council for Palliative Care and NHS Choices have produced guidance for patients, families, health and social care professionals regarding End of Life Care and Advance Care Planning. The guide can be accessed here.