Emergency Medical Services (EMS) In Remote and Underserved Areas

Introduction:

The emergence of emergency services in rural and underserved areas has markedly decreased mortality rates in recent times. With the changing health trends and growing needs of communities like community-based palliative care, emergency care has witnessed constant evolution. EMS aims to provide equity in access, early detection, expert care, and effective incorporation of community-based palliative care. However, various structural, cultural, and practice barriers do exist which need to be addressed. EMS bridges the gaps in community health care practice by providing palliative and end-of-life care to patients who are otherwise deprived of the same due to cultural, social, economic, and geographical barriers.

What Is Palliative Care?

Palliative care refers to an initiative that aims at improving the quality of life through early detection, proper assessment, and catering better treatment options to avoid suffering in people and their families challenged with life-limiting health conditions.

What Is End-of-Life Care (EoLC)?

End-of-life care (EoLC) is the evaluation, care, and provision of treatment to patients who are at their end stage of life (12 months before death).

How Can the Public Health Palliative Care Utilize the Emergency Medical Services (EMS)?

• EMS is an integral part of the healthcare delivery system as it bridges the gap between in-hospital settings and community-based patients.

• EMS has the advantage of round-the-clock availability and mobility, providing access to health care in remote areas.

• Along with its emergency service, it also caters to palliative care in underserved areas and provides transport facilities to hospital set-ups for more complex care, which is beyond the scope of EMS.

• EMS also offers significant adjunct in-home health care in isolated areas at odd hours, especially when other palliative care services are unavailable.

• People with low socioeconomic status (SES) and the ones living in remote areas are prone to face transport challenges in obtaining palliative care.

• The timely provision of palliative care positively impacts the patients and their family’s quality of life (QoL), satisfaction, and confidence.

• EMS offers care in EoLc (end-of-life care) emergencies like acute pain, dyspnea, convulsions, and sudden loss of consciousness to aging patients who are in dire need of the same.

• Collaborating EMS with other palliative care services provides equal health care to everyone who is in need and improves the overall healthcare delivery system.

• The integration of EMS and palliative care proves to be cost-effective by making use of available resources and reducing unnecessary hospital visits.

What Are the Barriers Preventing Public Health Palliative Care Approaches to EMS?

• EMS systems provide emergency treatment and conveyance to patients to reach the tertiary facilities.

• Delivering EMS to patients who are at the end of life faces many challenges, as transportation is undesirable in such cases. Although palliative care is attempted in such scenarios, deviation from standard practice may attract fear of litigation in such cases.

• EMS providers’ decision-making is often challenged by medico-legal documentation in palliative situations, as advance directives (AD) and do-not-resuscitate (DNR) approaches are commonly employed in difficult situations. However, these documents create confusion as there are no clear guidelines to follow, and the validity of such procedures might be questioned.

• The non-flexibility of the EMS system and the fear of medico-legal litigations prevent the EMS person from conducting alternate modes of treatment in palliative cases.

• The EMS mainly focuses on preserving life or limb until definitive care is reached.

• EMS providers are often trained to intervene invasively in life-threatening situations to give timely and definitive care. Such procedures are considered improper and inappropriate according to palliative care principles.

• The structural and cultural barriers related to EMS have been solved to some extent. However, the limited scope of EMS availability, limited resources, and complex nature of community-based settings still pose a great challenge in delivering optimum EMS to the community.

• The out-of-hospital setting with limited facilities in an uncontrolled environment may further act as a barrier to providing palliative care.

What Are the Steps Taken to Address the Barriers Encountered in EMS?

• EMS needs to be incorporated into national and international public health palliative care policies and frameworks to work on the barriers.

• An initiative called the Healthy End-of-Life Program (HELP) partnership framework has been developed to incorporate a preliminary public health palliative care approach to the emergency medical services framework proposal.

• The framework works to recognize EMS as a bridge linking formal (health and social services) and informal (community) networks of palliative care, offering equitable access for remote and isolated communities.

• The framework strives to overcome structural, cultural, and practice barriers recognized by collaborating health and social services with the communities to enable reliable outcomes.

• As a result, a public health palliative care approach to EMS supports the integration of alternative pathways, encourages multidisciplinary teams of care, reduces avoidable hospital admissions, and facilitates home-based deaths.

• To overcome the significant cultural barriers facing EMS in delivering palliative care, clinician attitudes and perceptions regarding the role of EMS must first evolve. Palliative care fundamentals ought to be imbibed in education, beginning at an undergraduate/student curriculum level.

• Those exhibiting a particular aptitude or passion for palliative care need access to further opportunities to gain advanced practical training in palliative care, allowing these EMS personnel to become champions within their respective service and contribute to the ongoing sustainability of palliative care expertise.

• Investing in the research and implementation of alternate referral pathways for EMS caring for palliative patients in the community must also be prioritized.

• Embedding a public health palliative care approach to EMS into health systems will ultimately facilitate community preferences to die in place and avoid hospitalization where appropriate.

Conclusion:

A public health approach to palliative and EoLC acknowledges and facilitates the contribution everyone can make in improving the experiences of seriously ill and dying people. The EMS sector, in particular, offers valuable resources and skills distinct from other services that position them to provide expertise and support in situations that would otherwise go unmet.