Investigating the impact of ambulance service models on paramedic delivery of end-of-life care in England: an exploratory study using case study design.

BACKGROUND: Rising demand for end-of-life care in developed countries, driven by ageing populations and multimorbidity, has led to increased calls to emergency ambulance services. Despite this little is known about paramedic practice in this context and service provision varies. As part of a wider study evaluating paramedic delivery of end-of-life care, in-depth case studies were undertaken to investigate how different models of ambulance service shape paramedic practice and influence experiences.

METHODS: Embedded case study design. The unit of analysis for each case comprised a distinct service model. Three ambulance services in England, UK were selected for their end-of-life service specifications. Semi-structured interviews and focus groups were undertaken with patients, family carers and healthcare professionals and data extracted from ambulance patient records. Qualitative data were analysed using Framework Analysis and patient ambulance record data using descriptive statistics and directed content analysis. Data were collected in parallel and analysed together utilising a mixed method, convergent parallel design. Integration occurred initially within cases, then across the cases.

RESULTS: Three cases were studied. They represented a usual model of end-of-life care delivery (Case 1) and more innovative models (Cases 2 & 3). Anticipatory medicines were carried by advanced paramedics in Case 2, and Case 3 had an in-service specialist palliative care team and access to palliative care ambulances. One hundred and one (n = 101) individuals participated, including n = 75 healthcare professionals and n = 26 patients and carers. In all cases, paramedics worked hard to provide supportive care, often attending due to primary and community service shortages. Learning on the job and limited access to essential resources (patient healthcare records, anticipatory medicines and/or palliative care advice) dominated practice across the cases. Access to advanced paramedics who carry anticipatory medicines in Case 2 and palliative care ambulances in Case 3 facilitated care provision and improved patient outcomes (death in preferred place).

CONCLUSIONS: This study provides an in-depth exploration of paramedic practice at end-of-life via case studies of service models. To best support paramedics in practice, services should facilitate end-of-life care training, access to and ability to administer medicines, and promote interdisciplinary collaboration, underpinned by access to shared digital patient healthcare records.