EMS responses to hospice patients: a qualitative study

1In the palliative care community, multiple emergency department visits and hospitalizations are considered an indicator of poor-quality end of life care. There is substantial research on the events surrounding ED visits, and subsequent hospitalizatons, by hospice patients. It is important however to understand that these hospital arrivals often begin with an ambulance response to the home. Emergency medical services (EMS) responses to hospice patients have been less well-studied. We conducted a retrospective study of 170 consecutive electronic patient care reports produced contemporaneously by EMS providers in several US counties during the normal course of their responses to hospice patients. We summarized descriptive epidemiology of the patients and of the incidents, and we explored the provider narratives for recurring themes. To our knowledge this is the first study to explore the contemporaneously-documented on-scene circumstances of pre-hospital care for patients enrolled in a hospice program. The median patient age was 76. Cancer, chronic lung disease, and heart failure were the most common hospice-qualifying diagnoses. Transportation of the patient from the scene occurred in 111 cases (65.3%). Consistent with previous studies based on interviews of EMS providers, the most common chief complaints included pain, dyspnea, and altered mental status. EMS was frequently called for confirmation of death, a finding not previously reported. Transitions of care, such as from curative medical care to hospice care, and from hospital to home, were a recurring theme. Gaps in care around these transitions were often evident, with EMS being called upon to fill them. Care transitions around weekends were prominent. Also emerging from the narratives was the concept that hospice enrollment is not a single event but rather a step-wise process; we developed a preliminary coding taxonomy to classify those enrollment stages. The hospice-EMS interface can be complex. Although all care by EMS providers is with the literal or implied consent of the patient, the arrival of an ambulance to a scene where emotions are running high carries a certain momentum and could lead to a cascade of interventions that, in retrospect and given other options, the patient may not have wanted. A better understanding of the hospice-EMS interface might illuminate changes that could be made to improve it, with a goal of ensuring that hospice patients and their families receive emergency medical services when they need and can benefit from them but receive other, non-EMS, services when those are more suitable to their needs. It might also improve the efficiency of an already overburdened EMS system.