25 October 2021
By NSW Ambulance
This fact sheet, created by NSW Ambulance, gives health practitioners a better understanding of the role paramedics play in community palliative care.
Paramedic Role
- Paramedics are highly trained clinicians and registered health professionals who respond to Triple Zero (000) calls and provide patient-centered care in the out-of- hospital setting
- Paramedics are authorised to work within the NSW Ambulance Protocols and Pharmacology clinical scope. These clinical guidelines provide a robust and evidence- based framework to ensure that paramedics deliver safe and high-quality care to patients
Care Approach
- When they arrive on the scene, the paramedic will perform a comprehensive clinical assessment, gather information about the patient and initiate the appropriate medical care based on the presenting situation
- To determine a patient’s need at the point of care, the paramedic will engage in shared decision-making with the patient, and as required, family members, carers, specialist providers and primary health clinicians
- Following this, the paramedic will assess the patient’s ongoing needs and identify the safest and most appropriate pathway to connect patients to the right level of care
Information that guides paramedic decision making includes (but is not limited to):
- Advance Care Planning documents including an Advance Care Directive and Enduring Guardian paperwork
- Conversations with patients, families or caregivers
- Patient health summary from the existing care provider
- Referral contact details such as specialist service providers or primary health clinicians
- Recent discharge summaries
- Prescribed medications
- Death Certification Arrangements for Expected Home Death
Palliative Care
Paramedics provide high quality, compassionate palliative care through a combination of:
- comprehensive assessment, identification and management of reversible conditions
- administration of medication to manage distressing symptoms
- non-pharmacological symptom management and support
- initiating contact with the patient’s existing care providers and referring for ongoing management
- withholding unwanted interventions
- supporting families and carers
- transporting to an emergency department
- completing a Verification of Death (VoD) assessment
2020 Protocol and Pharmacology enhancement
- NSW Ambulance expanded the paramedic scope of practice in the 2020 Protocol and Pharmacology update to incorporate medications administration for the management of distressing palliative care symptoms
- This protocol enhancement provides further flexibility and broadens the paramedic skillset, to respond to and manage patient needs at the point of care
- Now that palliative care medications are within the paramedic scope of practice, doctors do not need to submit a NSW Ambulance Authorised Care plan for patients to receive palliative care medications
Paramedic Scope of Practice
Palliative Care Protocol
- Paramedics can provide pharmacological symptom management for the following common end-of-life symptoms:
- morphine for breathlessness and pain (2.5mg – 5mg subcutaneous. Nil repeat)
- midazolam for agitation, anxiety or breathlessness (2.5 mg – 5 mg subcutaneous. Nil repeat)
- droperidol for nausea and vomiting (0.5 mg subcutaneous, repeat after 8 hours)
- This is in addition to the existing paramedic scope of practice, where paramedics already deliver high quality symptom management for a range of conditions
Pain Management
- Paramedics can administer a range of analgesic agents including paracetamol, ibuprofen, morphine, fentanyl (intranasal), and methoxyflurane
- The addition of subcutaneous morphine for breathlessness broadens the paramedic scope to provide symptom relief for palliative care patients experiencing distressing symptoms associated with pain
Nausea and Vomiting
- For the management of nausea and vomiting, paramedics have a range of anti-emetics within their scope of practice. Paramedics can administer ondansetron, metoclopramide and droperidol
Goals of Care
- In emergency situations, documented goals of care, or the presence of an individual(s) able to articulate the goals of care if the patient cannot do so, helps to ensure appropriate care is provided
- The Advance Care Directive is a legally binding, patient initiated document that articulates goals of care and must be adhered to
- Completing an Advance Care Directive improves the likelihood of matching patient preferences with outcomes and is the preferred format to document patient’s end of life preferences
Authorised Care Plans
- Now that paramedics can provide palliative care without an endorsed NSW Ambulance Authorised Care Plan, there is no need to submit a plan for your patient.
- NSW Ambulance Authorised Care Plans are not legally binding unlike an Advance Care Directive. A NSW Ambulance Authorised Care Plan may only be used as guidance for a paramedic to better understand the whole patient picture and facilitate, not instruct, clinical decision making.
- NSW Ambulance is in the process of further expanding the paramedic palliative model of care. Given the expansion of the paramedic palliative model of care, the NSW Ambulance Authorised Care Plan program will only continue to operate on a much narrower and limited basis. An Authorised Care Plan is not required for patient care that is within the current scope of paramedic practice.
- Requests for plans outside paramedic scope of practice will be reviewed by the NSW Ambulance MedicalDirector on a case-by-case basis, and the submitting health practitioner will be advised of the endorsement outcome.
- Health practitioners can be confident that paramedics will continue to advocate for their patients, and provide caring, compassionate palliative and end-of-life care.
Website: Visit the NSW Ambulance website for more information on Authorised Care Plans
For more information download this document