Paramedic utility in screening patients who present to Emergency Medical Services and who may benefit from an Advance Care Plan: A mixed methods study with explanatory sequential design

Figures & data

Table 1 Characteristics of paramedic participants

Participant ID	Years experience as fully qualified paramedic	Sex
1	17	F
2	2	M
3	5	M
4	3	M
5	10	F
6	5	M
7	4	M
8	16	F
9	8	F
10	12	F

Figure 1 Advance care planning breakdown by type where patient was screened as the end of life by the paramedic and advance care planning was in place. Note: Do No Attempt Cardiopulmonary Resuscitation (DNAR), Recommended Summary Plan for Emergency Care and Treatment process (ReSPECT), Treatment Escalation Plan (TEP), Unknown (U/K).

Figure 2 Themes and sub-themes.

Table 2 Interview quotes

Quote number	Quote
Theme 1: Participant experience of using the GSFPIG
1a	P02 ‘It’s quite simple to work out with the flowchart and with the leaflet and the decline and which kind of decline they go into, I found it useful at times when I didn’t know’
1b	P04 ‘Initially quite complicated. I still have my paper copy of it kind of to hand’
1c	P05 ‘ … you ask the question “Would you be surprised if they were to pass away in the next twelve months”? if it’s not obvious, the … the breakdown of it where you ask the … you know, they go through the … (General Indicators of Decline) Yeah, and that helps to kind of break it down and, yeah, make it clear as to whether somebody you would … you think somebody is in the last twelve months of their life. So, yeah, I find it really easy to use’
1d	P06 ‘Maybe if I was transporting to hospital, I would probably think about it less, because, I don’t really know why, but I don’t think about it as much. Maybe I think the hospital can sort it out, which isn’t necessarily true’
1e	P07 ‘It’s something that if I look at now more, before it was just going to people and okay, they are old and they maybe end of life, but it’s something that I never really took much notice in, it’s just their ongoing care, and I’ve been concerned and referred them to the hospital or whatever, so now it has definitely changed the way I look at them in the early thing, and if there is anything in place, or it should be in place, it’s definitely changed the way that I see part of patient care, definitely’
Theme 2: Putting a screening and referral tool into practice
2a	P01 ‘What … what people don’t realise is a lot of the … a lot of the time it’s not an emergency, it’s a more urgent care call that we go to, and I certainly think that in those situations yeah, I absolutely think that we … we … we’re able and in a good position to have those conversations because we are at their home, we get a good picture of their social background, the way they live, what support they have, how they’re coping at home because we can see that … ’
2b	P04 ‘ … people decline and they don’t go to the doctor’s for various reasons, you know, fear, anxiety, not being able to get appointments, not even realising that they’re declining on there, and suddenly something happens and we’re the first ones there … ’
2c	P06 ‘I think there needs to be a template on the ePCR so you can pick a template and then it will collate the information from the main record and then basically put it in a format that says this patient needs end of life planning documentation completed. Then, that specifically sent by email to them (primary care), so it comes up as one form rather than being lost within an entire record that they are probably not going to have time to read’
2d	P01 ‘I think perhaps we would need some additional … potentially some additional end-of-life … or not even additional … more regular end-of-life care training just so that they’re much more comfortable with … with dealing with that sort of thing’
2e	P03 ‘ … potentially the stuff before gets forgotten a little bit and your focus is always on what you’re sort of focusing on at the moment … ’
2f	P06 ‘I think it would need to be promoted if it was going to be of any use, because people are just too busy and have too much other information going on that they wouldn’t notice it’
2g	P08 ‘But I think as a profession, when we start talking about end of life we do get a bit scared and clam up. So, yeah, something on communication would definitely help’
2h	P05‘I think some people could be quite abrupt and be like “Yeah, I’ve just screened you and … and you’re end of life” and yeah, I can see how that would … I can see that some people would do that and I can see how that would come across’
2i	P04 ‘I am certainly very conscious that there’s other patients waiting, and so is the Trust, so they’re keen to push us and try and performance manage us to bish bash bosh, go onto the next one … ’
2j	P05 ‘ … it almost seems more appropriate to do it as an email, but it’s nice to be able to have that conversation with a person. It’s difficult because you can say so much more in words … ’
2k	P10 ‘ … because you could also see actually, last week they saw their GP and they had this discussion and this was the plan that was made, and actually in two days’ time, they’ve got someone visiting to do this care planning already … ’
2l	P01 ‘ … the volume (referrals) of the … the volume’s going to be, oh, so much, I can imagine’
2m	P05 ‘ … I don’t … I don’t know if it would make a huge amount of difference because they’re so snowed under, the GPs, I don’t know that they’d find the time to actually do that (pick up referral)’
2n	P06 ‘Lots of GP practices have paramedics and nurses that work for them, so I would probably say, one of them. They would be really well placed to do the care planning there (care home), but also, they could take on cohorts of patients that are referred from us’
Theme 3: Paramedic views on ACPs
3a	P09 ‘ … in terms of non-conveyance, it would make our lives a lot easier. There have been plenty of times when patients are meant to have an ACP of some sort and they haven’t, or it’s not been there with the patient. Then you have ended up in a conundrum about, do I convey? Don’t I convey? Then the answer is, if in doubt, where do you go? Hospital. Then you get to hospital and they go, ah, I can see on the records she has a … you think no, I have just brought you someone here I shouldn’t have brought you, but what can you do?’
3b	P06 ‘ … it’s something that is helpful and is necessary, and it’s better for the patient and the patient’s family when they know what the plan is … ’
3c	P02 ‘Certainly a massive volume. If we take care homes into consideration, this is where we highlight the majority of our patients who are probably in their last year of life with nothing set up, maybe a DNR if we are lucky, but no TEP plan and they don’t all have power of attorney. A majority of the patients I go to nursing homes with aren’t set up to have a peaceful death. It waits for them to become really unwell and have the ambulance service turn up … ’
3d	P09 ‘ … It is only when they really critical that some doctor goes, oh we should discuss DNR’s and it’s like, well, at that point actually are they in a position to discuss DNR? The man is having a massive stroke and you are just suddenly poking it on him. It’s actually almost better to have it early … ’
3e	P03 ‘ … but the trouble was like four o’clock in the morning, there hadn’t been sort of any … not … very, very little discussion before, you know, we … the patient did have a lasting power of attorney but we couldn’t get hold of any of the family, and then you’re just left in that … I mean, I don’t mind having difficult conversations with relatives and patients but there’s a time and a place, you know, phoning a relative at four in the morning and, you know, saying “Well, do you want us to drag your mum out of her warm bed and into hospital?” is … it just feels really wrong, so the more we can have of this, the better, I think’
3f	P07 ‘A lot of the time people have TEPs and we don’t see them. Then the family and the doctor, go oh yeah, they have a TEP, and we go, well, there’s no TEP here … but if we haven’t got it there, or a copy of it, we don’t know. A lot of patients have TEPs but we haven’t actually seen them’
3g	P08 ‘ … the easiest option, take somebody to hospital because it … on that box it’s ticked that it is for admission. I think around that area, you know, if there was some more clarity, that would prevent an awful lot of our admissions and an awful lot of the unsureness of the decision that … you know, to make’
3h	P08 ‘And the … the patients sometimes don’t even know what it is. So, you know, we’re … we’re saying do you have a TEP form, “Oh what’s that”? A treatment escalation … did you get a red form when you were discharged? “Oh yeah, I’ve got that in an envelope somewhere”. And then I’ll say “Do … do you know what this is, do you understand what it is”? “Oh no, I … the … the doctor just gave me that”’
3i	P09 ‘Even if you book a double appointment, are you potentially going to get to the point where you are going to feel comfortable to say, actually, Doctor, I have been having some thoughts and feelings about my health and don’t want to be resuscitated’
3j	P01 ‘Okay. So, yeah, most of the time it is generally just a do not resuscitate order, and occasionally they may have selected things like no artificial feeding, no intensive care, those sorts of things … ’
3k	P04 ‘ … Some of them, it’s pages, and pages, and pages but with very little actual information in it … ’
3l	P09 ‘My least favourite sentence is, people are for admission for treatable problems. What on earth does that mean … ?’
3m	P04 ‘ … (the) Future Care Plan was written four years ago, that says “Oh, you know, I want absolutely everything” and then you actually speak to the patient and they go, “I really don’t. I’m exhausted. I’m tired. I want to stay at home”’
3n	P04 ‘ … you’ve got ninety-year-old Bob, and ninety-one-year-old Doris who have been married for seventy-odd years and we … we’re kind of going, “Well, actually Bob’s going downhill really quite rapidly on there”, but we’re not going to say anything to Doris because … for fear of upsetting her and whatever, when actually she needs to be part of that, that … that’s part of, you know, the process of going … it’s not just supporting the end of life stuff, it’s supporting the grieving process afterwards … ’
3o	P05 ‘But the other side of it, you’ve got the … the family and carers that just want the patient to go into hospital when they see them deteriorating and then the patient doesn’t want to and it’s not really all that appropriate, but they’re not … because they’ve never … no one’s ever said to them, you know, that your loved one is approaching the end of their life, they kind of still want them to go to hospital, or maybe it was because they want them to die in hospital, that’s what some people want. But it’s because I think the difficult conversations aren’t being had earlier on, you know, which is why I think it’s really good if we can get advance care planning started, it’s a really good thing because it would enable a lot more people to just comfortably and at peace and without it being such a scary process for them and their families’