Palliative Care and Prehospital Emergency Medicine

Palliative care, which is intended to keep patients at home as long as possible, is increasingly proposed for patients who live at home, with their family, or in retirement homes. Although their condition is expected to have a lethal evolution, the patients—or more often their families or entourages—are sometimes confronted with sudden situations of respiratory distress, convulsions, hemorrhage, coma, anxiety, or pain. Prehospital emergency services are therefore often confronted with palliative care situations, situations in which medical teams are not skilled and therefore frequently feel awkward. We conducted a retrospective study about cases of palliative care situations that were managed by prehospital emergency physicians (EPs) over a period of 8 months in 2012, in the urban region of Lausanne in the State of Vaud, Switzerland. The prehospital EPs managed 1586 prehospital emergencies during the study period. We report 4 situations of respiratory distress or neurological disorders in advanced cancer patients, highlighting endof-life and palliative care situations that may be encountered by prehospital emergency services. The similarity of the cases, the reasons leading to the involvement of prehospital EPs, and the ethical dilemma illustrated by these situations are discussed. These situations highlight the need for more formal education in palliative care for EPs and prehospital emergency teams, and the need to fully communicate the planning and implementation of palliative care with patients and patients’ family members. (Medicine 93(25):e128) Abbreviations: EMS = emergency medical services, EP = emergency physician, GCS = Glasgow Coma Scale, GP = general practitioner. INTRODUCTION L ike the populations of other occidental countries, the western European population is gradually aging. This evolution , MD, MBA, Fatou , MD, ivier Hugli, MD, MPH cardiovascular diseases, oncologic pathologies, or dementia. Many of these patients benefit from high-level and costly treatments throughout their lives, particularly at the final stage of their illness. Most of these treatments are prescribed as ‘‘home treatments’’ to keep the patients at home as long as possible. This strategy is in accordance with the desire expressed by most patients to spend the last part of their lives at home and is reinforced by political and economic strategies intended to develop ambulatory care and home treatments. In this context, palliative care, intended to keep patients at home as long as possible, is increasingly proposed for ambulatory patients who live at home, with their family, or in retirement homes, through ambulatory palliative networks. Although their condition is expected to have a lethal evolution, the patients—or more often their families or entourages—are sometimes confronted with situations of respiratory distress, convulsions, coma, anxiety, or pain. In these situations, the patients or their families feel helpless and overwhelmed, and they seek external assistance through the ambulatory palliative network, when possible and appropriate, or through on-call medical assistance. At the same time, the evolution of the demographics and organization of the medical profession has reduced the number of primary care physicians, and their oncall availability—though variable—is decreasing globally. Prehospital emergency services are therefore more often confronted with palliative situations, situations in which medical teams are not specifically trained and therefore frequently feel awkward. The management of these situations is complex and requires time to understand the situation, to evaluate the therapeutic options, to seek the wishes of the patients, to follow the advance directives concerning medical care in case of emergency, and to offer palliative care with empathy and respect for ethical principles. Time may be difficult to offer, for emergency teams who can potentially be called to another emergency situation at any moment. The risk of not respecting the wishes of the patient and of aggressive and futile therapy is considerable, and specific treatments, such as analgesia, sedation, or anxiolysis, are not necessarily well mastered in these palliative situations.