The use of emergency medical services for palliative situations in Western Cape Province, South Africa: A retrospective, descriptive analysis of patient records
Keywords:Emergency Medicine, Palliative care, Emergency Medical Services, Paramedic
Background. An estimated 56.8 million people require palliative care annually, while only 14% receive such care. This imbalance is particularly acute in low-to middle-income countries (LMICs), where up to 80% of patients requiring palliative care reside. To correct this imbalance, integration between palliative services and other disciplines has been recommended. While improved palliative care integration is a priority in the South African (SA) LMIC context, emergency medical services (EMS) and palliative care remain non-integrated. This has resulted in poor palliative situation management by EMS and a lack of research concerning their intersection.
Objective. To examine EMS use for palliative situations in the Western Cape (WC) Province of SA by describing frequency of intersection, patient characteristics and outcomes.
Methods. An observational, descriptive, retrospective patient record review was employed at two hospitals with palliative care services in the WC. All patient records of those who arrived at the hospitals between 1 January 2020 and 31 December 2020 via EMS conveyance leading to palliative care provision were included in the study.
Results. In total, 1 207 unique patients received palliative care services at both hospitals during the study period. Of these, 395 (33%) made use of EMS for hospital conveyance on 494 occasions. The median (range) patient age was 60 (20 - 93) years, and most transports involved male patients (54%, n=265). Family members were the primary caregivers in most instances (89%, n=440), dyspnoea was the chief complaint (36%, n=178) and cancer was the most frequent diagnosis (32%, n=159). The median length of hospital stay was 6 days, with most patients discharged home (60%, n=295).
Conclusion. EMS in SA frequently encounter palliative situations for symptoms that may be managed within their scope of practice. Consequently, it appears that EMS have an important role to fulfil in the care of patients with palliative needs. Integrating EMS and palliative care may result in improved palliative care provision and, therefore, EMS and palliative care integration would be beneficial in SA.
World Health Organization. Assessing the development of palliative care worldwide: A set of actionable indicators. Geneva: WHO, 2021. https://apps.who.int/iris/handle/10665/345532 (accessed 29 May 2023).
JuhrmannML,VandersmanP,ButowPN,ClaytonJM.Paramedicsdeliveringpalliativeandend-of-life care in community-based settings: A systematic integrative review with thematic synthesis. Palliat Med 2022;36(3):405-421. https://doi.org/10.1177/02692163211059342
Poudel A, Bhuvan KC, Shrestha S, Nissen L. Access to palliative care: Discrepancy among low-income and high-income countries. J Glob Health 2019;9(2):1-5. https://doi.org/10.7189/jogh.09.020309
Van der Plas WY, Benjamens S, Kruijff S. The increased need for palliative cancer care in Sub-Saharan Africa. Eur J Surg Oncol 2020;46(7):1373-1376. https://doi.org/10.1016/j.ejso.2020.03.212
World Health Organization. Palliative care. Geneva: WHO, 2020. https://www.who.int/news-room/ fact-sheets/detail/palliative-care (accessed 29 May 2023).
Gage CH, Stander C, Gwyther L, Stassen W. Emergency medical services and palliative care: Protocol for a scoping review. BMJ Open 2022;12:e062054. https://doi.org/10.1136/bmjopen-2022-062054
Gage CH, Stander C, Gwyther L, Stassen W. Emergency medical services and palliative care: A scoping
review. BMJ Open 2023;13:e071116. https://doi.org/10.1136/bmjopen-2022-071116
Kamphausen A, Roese H, Oechsle K, et al. Challenges faced by prehospital emergency physicians providing emergency care to patients with advanced incurable diseases. Emerg Med Int 2019;2019(2):1-
Pillay-van Wyk V, Msemburi W, Laubscher R, et al. Mortality trends and differentials in South Africa
from 1997 to 2012: Second National Burden of Disease Study. Lancet Glob Heal 2016;4(9):e642-653.
University of Pretoria. Palliative Care Resources. Pretoria: UP, 2017. https://www.up.ac.za/media/
(accessed 17 May 2019).
Burger H, Krause R, Blanchard C, et al. Position paper on undergraduate palliative medicine
education for doctors in South Africa. Afr J Prim Health Care Fam Med 2022;14(1):e1-e7. https://doi.
National Department of Health, South Africa. National Policy Framework and Strategy on Palliative Care 2017 - 2022. Pretoria: NDoH, 2017. https://www.health.gov.za/wp-content/uploads/2020/11/ NationalPolicyFrameworkandStrategyonPalliativeCare20172022.pdf (accessed 29 May 2023).
Gage CH, Geduld H, Stassen W. South African paramedic perspectives on prehospital palliative care. BMC Palliat Care 2020;19(1):153.
Benchimol EI, Smeeth L, Guttmann A, et al. The REporting of studies Conducted using Observational Routinely-collected health Data (RECORD ) Statement. PLoS Med 2015;12(10):e1001885. https://doi. org/10.1371/journal.pmed.1001885
Western Cape Government, South Africa. Population data. Western Cape Government: 2020.
data.pdf (accessed 29 May 2023).
South Africa. South Africa’s people. South Africa, 2021. https://www.gov.za/about-sa/south-africas-
people (accessed 29 May 2023).
Statistics South Africa. General household survey 2021. Pretoria: Stats SA, 2021. https://www.statssa.
gov.za/publications/P0318/P03182021.pdf (accessed 29 May 2023).
www.westerncape.gov.za/dept/health/documents/public_info/W/19578?toc_page=4#:~:text=Level 1 -
district hospitals where,Red Cross and Tygerberg hospitals (accessed 29 May 2023).
Health Professions Council of South Africa. Emergency Care. Pretoria: HPCSA, 2023. https://www. hpcsa.co.za/?contentId=0&menuSubId=45&actionName=Professional Boards (accessed 29 May
Gilbert EH, Lowenstein SR, Koziol-McLain J, et al. Chart reviews in emergency medicine research:
Where are the methods? Ann Emerg Med 1996;27(3):305-308. https://doi.org/10.1016/s0196- 0644(96)70264-0
Surakka LK, Peake MM, Kiljunen MM, et al. Preplanned participation of paramedics in end- of-life care at home: A retrospective cohort study. Palliat Med 2021;35(3):584-591. https://doi. org/10.1177/0269216320981713
Carter AJE, Arab M, Harrison M, et al. Paramedics providing palliative care at home: A mixed- methods exploration of patient and family satisfaction and paramedic comfort and confidence. CJEM 2020;21(4):513-522. https://doi.org/10.1017/cem.2018.497
Wiese CHR, Bartels UE, Marczynska K, et al. Quality of out-of-hospital palliative emergency care depends on the expertise of the emergency medical team – a prospective multi-centre analysis. Support Care Cancer 2009;17(12):1499-1506. https://doi.org/10.1007/s00520-009-0616-4
Lord B, Andrew E, Henderson A, et al. Palliative care in paramedic practice: A retrospective cohort study. Palliat Med 2019;33(4):445-451. https://doi.org/10.1177/0269216319828278
Juhrmann ML, Grindrod AE, Gage CH. Emergency medical services: the next linking asset for public health approaches to palliative care? Palliative Care and Social Practice 2023;17:1-11. https://doi. org/10.1177/26323524231163195
Waldrop DP, Clemency B, Lindstrom HA, Cordes CC. ‘We are strangers walking into their life- changing event’: How prehospital providers manage emergency calls at the end of life. J Pain Symptom Manage 2015;50(3):328-334. http:// doi.org/10.1016/j.jpainsymman.2015.03.001
International Association for Hospice and Palliative Care. IAHPC List of Essential Medicines for Palliative Care. Houston: IAHPC, 2007. https://hospicecare.com/what-we-do/projects/palliative-care- essentials/iahpc-essential-medicines-for-palliative-care/ (accessed 29 May 2023).
Wiese CHR, Barrels UE, Graf BM, Hanekop GG. Out-of-hospital opioid therapy of palliative care patients with ‘acute dyspnoea’: A retrospective multicenter investigation. J Opioid Manag 2009;5(2):115-122. https://doi.org/10.5055/jom.2009.0013
Dent T, Tipping I, Anderson R, Daniels C. Hospice advice and rapid response service for ambulance clinicians. BMJ Support Palliat Care 2020;10(3):296-299. https://doi.org/10.1136/bmjspcare-2019-001911
Rosa A, Dissanayake M, Carter D, Sibbald S. Community paramedicine to support palliative care. Prog Palliat Care 2021;30(1):1-5. https://doi.org/10.1080/09699260.2021.1912690
Eaton-Williams P, Barrett J, Mortimer C, Williams J. A national survey of ambulance paramedics on the identification of patients with end of life care needs. Br Paramed J 2020;5(3):8-14. https://doi.org/ 10.29045/14784726.2020.12.5.3.8
Swetenham K, Grantham H, Glaetzer K. Breaking down the silos: Collaboration delivering an efficient and effective response to palliative care emergencies. Prog Palliat Care 2014;22(4):212-218. https://doi. org/10.1179/1743291X13Y.0000000076
Gomes B, Higginson IJ, Calanzani N, et al. Preferences for place of death if faced with advanced cancer: A population survey in England, Flanders, Germany, Italy, the Netherlands, Portugal and Spain. Ann Oncol 2012;23(8):2006-2015. https://doi.org/10.1093/annonc/mdr602
Ratshikana-Moloko M, Ayeni O, Tsitsi JM, et al. Spiritual care, pain reduction, and preferred place of death among advanced cancer patients in Soweto, South Africa. J Pain Symptom Manage 2020;60(1):37-47. https://doi.org/10.1016/j.jpainsymman.2020.01.019
Gysels M, Pell C, Straus L, Pool R. End of life care in sub-Saharan Africa: A systematic review of the qualitative literature. BMC Palliat Care 2011;10:6. https://doi.org/10.1186/1472-684X-10-6
Breyre A, Taigman M, Salvucci A, et al. Effect of a mobile integrated hospice healthcare program on emergency medical services transport to the emergency department. Prehosp Emerg Care 2022;26(3):364-369. https://doi.org/10.1080/10903127.2021.1900474
Copyright (c) 2023 C Gage, B Spies, K Crombie, L Gwyther, W Stassen
This work is licensed under a Creative Commons Attribution-NonCommercial 4.0 International License.
The SAMJ is published under an Attribution-Non Commercial International Creative Commons Attribution (CC-BY-NC 4.0) License. Under this license, authors agree to make articles available to users, without permission or fees, for any lawful, non-commercial purpose. Users may read, copy, or re-use published content as long as the author and original place of publication are properly cited.
Exceptions to this license model is allowed for UKRI and research funded by organisations requiring that research be published open-access without embargo, under a CC-BY licence. As per the journals archiving policy, authors are permitted to self-archive the author-accepted manuscript (AAM) in a repository.
Authors grant the Publisher the exclusive right to publish, display, reproduce and/or distribute the Work in print and electronic format and in any medium known or hereafter developed, including for commercial use. The Author also agrees that the Publisher may retain in print or electronic format more than one copy of the Work for the purpose of preservation, security and back-up.