Advance care planning in emergency care situations

Role of emergency health care and ambulance clinicians for individuals approaching end of life

There will be times when individuals approaching end of life, will receive emergency care either following an ambulance call-out or an emergency admission to hospital. These individuals may or may not have an advance care plan in place. In these situations, the role of emergency health care or ambulance clinician may include:

• Gathering information rapidly, in an unknown situation
• Recognising the dying process
• Providing treatment where appropriate
• Providing care at the individual’s preferred place of care where appropriate
• Ensuring that the individual and family / carers understand and are engaged with the plans
• Identifying situations where advance care planning may be needed (if not already present)

Resuscitation

At times health care providers may be in a position where they need to communicate with family / carers about the appropriateness of resuscitation for an individual nearing the end of life, in an emergency situation. This can be a difficult and distressing conversation for those involved, often under time pressure.

Some ideas to help approach these situations

• Find out whether the individual has already discussed this with family / carers. Do they have a Do Not Attempt Cardio-Pulmonary Resuscitation (DNACPR)* or ADRT* in place?
• What does/would the individual want?
• Avoid jargon or medical slang
• You can use expressions like: ‘Unlikely to return to their previous quality of life’ and ‘sick enough to die’
• Explain your findings clearly, using the individual’s name where possible
• Sensitively explain the dying process to family / carers (see discussion from Dr Kathryn Mannix in the video below)

*DNACPR and ADRT are also discussed in Unit 2.

Resuscitation Council UK
Given the complexities surrounding cardio-pulmonary resuscitation (CPR) decisions, please consult your current professional guidance, and current relevant pages on the Resuscitation Council UK website
resus.org.uk

Advance decisions to refuse treatment - A guide for health and social care professionals
ADRT principles are explored further here by NHS England
england.nhs.uk

Decision Making

Emergency situations can involve making decisions in a tight time frame. Below are some pointers that may help with decision making:

• What are the expectations of the individual and their family / carers?
• If the individual is unable to communicate, ask family / carers what the individual would want?
• When involving the family, what is their current awareness and understanding of the situation?
• Are there any supporting documents (advance care plans) with further information?
• Do I need to consult with others and share this decision with somebody? eg palliative care team or other individuals involved in the individual’s care
• If no advance care plan exists, how can I gather this information to support decision making? This might include involvement of the individual and family / carers, or consulting colleagues
• It can also help to explain to families something about the normal processes of dying

In the following video, Dr Kathryn Mannix talks about frequent features of the normal process of dying, which may help you in recognising when an individual is dying, and help you to communicate with family members about what they might expect.

Helping things to go well in emergency care situations

In Unit 1, Kieran Potts, Ambulance Clinician, discussed the challenges that ambulance crews face when arriving at the scene where they have been called to an individual who they think is approaching the end of life, but where they have limited information about the individual and their wishes for future care.

In the video below Kieran discusses what might happen in a situation where these issues have already been discussed and shared. He also discusses more generally the role of ambulance and emergency health care staff in relation to end of life care and advance care planning.

Initiating advance care planning discussions in emergency care situations

An emergency call-out or admission can provide an opportunity to initiate an advance care planning discussion, if one has not already taken place. This can then be followed up elsewhere.

• Individuals who have recurrent admissions to hospital might present cues for initiating advance care planning discussions. For example, an individual with a chronic condition may express their wishes to remain at home, or say that they do not wish to receive Cardio-Pulmonary Resuscitation (CPR).
• As a health care provider in an emergency setting, part of your role may be to sign-post them to relevant services for further follow-up and to have advance care planning conversations. These follow-up discussions may take place within the primary care setting with a clinician who knows and understands the individual’s history, but a hospital specialist or community team clinician may also be able to assist with the conversation.
• In these circumstances, words you could use, for example with individuals with recurrent admissions: ‘Have you thought about what your preferences would be if this happens again?’ and ‘Have you spoken to anyone about your wishes?’ or ‘Perhaps you could discuss this further with your GP?’
• A recent study (2021) by Imperial College, London, suggested that older people welcomed an advance care planning discussion following an emergency hospital admission.

Want to learn more? NIHR Evidence: Advance care planning is welcomed by older people after an emergency admission

Anticipatory (Just in Case) Medicines

If you work in an emergency care setting you may sometimes encounter Anticipatory or ‘Just in Case’ medicines

• Anticipatory or ‘Just in Case’ Medicines are sometimes offered towards the end of life
• These medicines are usually prescribed in advance, by the individual’s primary care or community team. However, the medicines can sometimes be prescribed quickly, when recognising rapid deterioration in an individual believed to be at the end of their life
• The medicines are intended to manage and relieve symptoms of breathlessness, respiratory secretions, agitation and new or break-through pain
• Usually, medicines at end of life are administered via the sub-cutaneous route as a bolus (single dose), and sometimes via a continuous syringe-pump
• Administration of these medicines must be done according to local and national policy. Please refer to your local and national professional guidelines when considering the use of these medicines
• All medicine administration must be clearly documented, and details and information need to be handed over to the professionals involved in the individual’s ongoing care
• Consider consulting with someone else within your organisation to share decision making, if you are in a position where administration of these medicines may be required