Paramedics bridging palliative care gap in county during provincial study

WELLINGTON COUNTY – Guelph-Wellington Paramedic Services (GWPS) is trying out a new way of helping palliative patients get the relief they need, when and where they need it—right in the comfort of home.

Paramedics here are now able, as of Oct. 4, to administer four new drugs to palliative patients in-house, without having to transport a person to hospital.

That means no more unnecessary and painful transfers from bed to uncomfortable stretchers; no more being wheeled through the biting cold of a dark winter morning; and no more laying under the fluorescent lights of an emergency room hallway shivering for hours while awaiting a bed and doctor to free up—all to get a dose of medication and be sent back home for the next time.

Previously, palliative patients could choose that ordeal or decline paramedic transport and continue suffering until someone from a community palliative care team became available to visit their home and administer needed drugs.

“We’re really filling a gap that’s been missed in the past,” GWPS training commander Paul Boshart told the Advertiser in a phone interview.

“Unfortunately, sometimes in the middle of the night, or [when] things change quite suddenly, the nurses or the doctors are not able to get out to see that patient and the family turns to 911,” Boshart said.

It also means patients, who are often immunocompromised, aren’t exposed to hospital-acquired infections.

And there’s also benefit to the amount of time paramedics are unavailable for other calls. Whereas offload delays—the standing in the hallway waiting for a bed to free—can last for many hours, paramedics would generally remain at home with a palliative patient for 90 minutes.

Palliative care is a holistic approach to ease suffering and optimize a person’s quality of life in their final days.

And while some end-of-life patients opt to be placed in a hospice to live out those final days, others wish to remain at home.

But the comfort of home can mean the discomfort of not having a medical professional handy to administer medication unavailable in the medicine cabinet when it’s needed.

GWPS is one of several paramedic services across Ontario participating in an expanded one-year trial of what the province calls a “treat and refer model,” initially trialed in Ottawa last year.

Paramedics treat the patient, belonging to Home and Community Care Support Services’ palliative care program, and refer that person back to the care team who will then follow up and determine why 911 was called and what can be done to better serve the patient.

The Advertiser reached out to Home and Community Care Support Services Waterloo Wellington for this story but did not hear back from communications advisor Rebecca Boucher to arrange an interview before press time.

When a 911 call comes in from one of the program’s participants, a dispatcher will be able to see a flag identifying their address as belonging to a palliative patient and relay that information to paramedics.

Boshart simplified: “It’s looking at resource utilization and respecting the patient’s wishes because really the patient does not want to go to the hospital—that’s why they’re at home.”

All of the service’s 182 paramedics received palliative training in September from Pallium Canada—six hours online and six in-person—and are currently able to provide palliative care in the county.

Primary care paramedics can administer haloperidol (Haldol) to treat hallucinations and agitation, glycopyrrolate (Cuvposa) for respiratory secretions, and ondansetron (Zofran) for nausea and vomiting.

Advanced care paramedics can also administer hydromorphone (Dilaudid), an opioid used to treat severe pain, in addition to the other three antipsychotic, anticholinergic and antiemetic drugs—the same drugs a palliative care nurse would have.

Drugs are paid for by the Ottawa Hospital Research Institute during the trial, but the service had to purchase new bags to accommodate the additional drugs and cover training costs.

Following at-home palliative service, paramedics will complete a survey collected internally and relayed to the province as part of its study analyzing new care models.

Should the expanded trial be a success, the province wants to roll out the new palliative care model Ontario-wide.

Future of pre-hospital medicine

Boshart believes the emergency medical system taking a more preventative approach, opposed to a solely reactionary role, is the future of pre-hospital medicine.

“I’m hearing that [staff are] very encouraged by this; they’re a little bit timid, because it’s completely against what we’ve done for years,” Boshart said, referring to the long-standing model of treat and transport—not treat and leave.

“We’re looking at creative ways to manage the calls we’re given without having to take them all to the emergency department which seems to be that chokepoint in the healthcare system,” Boshart said, adding the new model offers the service a treatment choice respecting the patient.

“This may just be a glimmer of the future of paramedicine … the door has been opened to many things, and if we can be successful with this, I think we can show that we might be able to do other things in the future,” he said.

The service is expected to be available to between 200 and 300 palliative patients in the community on any given day, but should the care model become a permanent option, the list of patients is likely to grow.

The province predicts 25 per cent of Ontarians will be at least 65 years old by 2041, amounting to 4.6 million seniors.

According to Waterloo Wellington Local Health Integration Network (LHIN) data, 17.6% of the county’s population is currently at least 65 years old.

The LHIN reported 44% of palliative care patients received home visits from care services within the last 90 days of life and were at home for 155 to 165 days before death.

Between 2016-17, 93% of palliative care patients were discharged from hospital for home support.