Palliative emergencies in the pre-hospital setting

Abstract

Objective: To provide a narrative on the most common palliative emergency situations that requires the attendance of a paramedic. This narrative looks specifically at pain, seizures and breathlessness, and critiques the underpinning evidence supporting their treatment and protocols. Discussion: Pain—the presence of pain in palliative care is highly prevalent with up to 70% of patients living in a permanent painful state. Clinician-led pain assessment has been shown to underestimate the patient's pain by as much as 60–68% and none of the assessment tools used are fully inclusive. Further research is needed to formulate an assessment tool that recognises palliative pain as a progressive disorder requiring constant assessment. Seizures—Seizures occur as either a result of disease progression or as a side effect of medications. Studies have shown that intramuscular midazolam is more effective than intravenous lorazepam, which is itself more effective than intravenous diazepam. The ease of administration of intramuscular and buccal midazolam for out-of-hospital use should make midazolam the first-line treatment for palliative care patients that suffer from seizures. The implication for future paramedic practice highlighted from these studies is the need for more research in the treatment of palliative patients with seizures. Breathlessness—Cold facial stimulation has been shown to be very effective as a non-pharmacological treatment for breathlessness. Opioids help to relax the patient which aid in regulating breathing patterns although a consensus on the route of administration which provides the best possible effect is yet to be reached. The evidence base for the use of anxiolytics is weak and some studies have shown no beneficial effect to their use. Although anxiolytics are effective in reducing anxiety their effectiveness in helping breathlessness in palliative patients is questionable. Home oxygen should be adopted as a first line treatment according to experts working in end-of-life care, and treatment of oxygen should not be delayed by waiting for results of other trials for other treatments.