EMS and Hospice Collaborate for Terminally Ill Patients

Can emergency medical transport professionals proceed at a different pace when called to help hospice patients, with the potential for a more personal patient bonding experience?

Hospice patients have a medical prognosis of six months or less to live, assuming their illness progresses as expected, according to Medicare’s definition. But while they may well die in the foreseeable future, they sometimes need assisted transport from their home to a hospital, a hospice inpatient unit, long-term care facility or medical appointment—and back. And while this journey may not be a high-stakes emergency, the patient’s experience and comfort should still be considered. That is also the aim of hospice care.

In other cases, hospice patients’ families may call 9-1-1 in a panic during a symptomatic crisis, potentially leading to escalating interventions that aren’t what the patient would have wanted. A number of hospice services and EMS providers have developed partnerships or other relationships to help ensure that these patients get a medical response that’s appropriate to their situation and needs.

That could involve special training, inputting a patient’s hospice enrollment status into the EMS database, or establishing a protocol to immediately call the hospice and/or send a hospice-trained community paramedic to the home in an emergency and perhaps avoid an unnecessary trip to the hospital. A recent survey of EMTs in Michigan found that only 24 percent had received any formal training in the care of hospice patients, but 86 percent were interested in receiving such training.1

One nonprofit hospice agency, Ohio’s Hospice LifeCare in Wooster, Ohio, has taken the concept a step further, creating its own regulated, ambulance-level mobile transport service and crew of EMTs, in order to ensure that its patients get the responsive transport they need.

How to Start the Conversation

Howard Capon, a mobile medicine clinician and public health professional in Arlington, VA, has been part of collaborations between EMS and hospice. “We recognized each other’s strengths,” explains Capon, who serves as EMS advisor to the national coordinating office for POLST (Physician Orders for Life-Sustaining Treatment), a portable medical order that can be honored by EMS in almost every state.

What can hospice and EMS do to create a plan that will work? “One or the other party has to reach out to start the conversation,” Capon says. A lot of agencies on both sides don’t know there is a problem until they run the numbers and see how many more hospice patients are getting ambulance rides than they realized.

“When we talk about the patient’s site of death, we want it to be in concordance with their expressed wish, which isn’t always to die at home,” Capon says, adding that it is also worth asking, “What am I accomplishing by bringing a hospice patient to the hospital for breathing issues or pain exacerbations?”

Some, though not all, hospice patients have a prehospital DNR order or signed POLST form, but these documents may not always be accessible to EMS personnel when needed. The patient may have discussed plans for dying peacefully at home without CPR. But when the moment of crisis arrives, the best-laid plans can go out the window. Best practice is to call the hospice first using its on-call after-hours line.

Capon points out that the variety in EMS agencies and systems, which often get lumped together, shapes what’s possible. Regulatory requirements also vary by state. It’s also important to acknowledge that in large swaths of this country right now, the EMS infrastructure is crumbling, with cuts in funding and major recruitment and retention issues, he says.

How Can EMS Partner with Hospice?

Mike Taigman, MA, FAEMS, improvement guide for FirstWatch, was in charge of the paramedic 9-1-1 system in Ventura County, CA, in 2012 when he was asked whether there was a way to avoid taking hospice patients to the hospital. “I said I’d do some research,” he said. “By using the right search criteria, I found 283 hospice patients that had been transported by EMS in the previous year.”

Taigman applied for a California Community Paramedic demonstration project, and assembled a team of EMS field supervisors to become community paramedics working to keep patients within the hospice system even when EMS is activated.² Taigman obtained authorization from the state for paramedics to take medical direction from hospice medical directors.

When the Ventura County EMS-hospice partnership went live, dispatchers or paramedics began calling a trained community paramedic when they realized a patient was hospice-enrolled. “We went from transporting 80 percent of hospice patients to the hospital when 9-1-1 was called to only transporting 17 percent,” said Taigman.³

Russ Myers, MDiv, chaplain with Allina Health Emergency Medical Services in Minneapolis-St. Paul, and author of the booklet Because We Care: A Handbook for Chaplaincy in Emergency Medical Services,⁴ is one of three EMS chaplains who regularly make scheduled rides with the Allina health system’s ambulance crews and address situations on the ground, including terminally ill patients. “My piece is the emotional response that has become part of our everyday work,” he explains.

“Our role as EMS chaplains is to provide whatever emotional or spiritual support is needed—to give the patient what they need. I also focus on our staff’s needs,” shares Myers, who calls this service the “other end of the spectrum” from high-tech emergency medical care. “It’s more like high-touch—a kinder, gentler approach. My message is that these are real people, not just another transport case. This is a moment they or their families could remember for the rest of their lives.”

In 2013, MedStar Mobile Healthcare, a governmental EMS provider serving Fort Worth, TX and surrounding communities, developed a collaboration with local home health and hospice providers, including VITAS Healthcare, using a community paramedic model. A computer-aided dispatch system notifies the MedStar call-taker whether a patient is entered as a hospice patient. Then a hospice-trained MedStar mobile healthcare practitioner (MHP) joins the ambulance response team dispatched to the patient, and the hospice is called. The MHP will work on the scene with the patient and family until the hospice nurse arrives.

From September 2013 through December 2021, 1,314 hospice patients were identified as being at greatest risk for discharge from hospice care in a crisis and enrolled in this program. Only 4.3 percent of them ended up disenrolling from hospice. VITAS, a national hospice company based in Miami, also partners with other EMS providers around the country to foster dialogue about alternate care options that can keep patients at home.

More Than Just a Milkshake

The biggest reason why Ohio’s Hospice LifeCare opted to develop its own ambulance service, starting in 2018, was to overcome long wait times for patients who needed transport. But it found that putting its own ambulance in the field was cost-effective as well. Hospices are responsible for covering all costs necessary and reasonable to manage their enrolled patients’ care, including the charges for ambulance rides.

“We had noticed that ambulance transport response for our patients who needed to move from one site to another often was delayed for hours because ambulance crews were called to ‘real emergencies,’” explains LifeCare’s CEO Kurt Holmes. “We knew that as a non-acute specialty we were often low on their priority list, but we wanted a service that would respond to our patients’ needs in a timely fashion.”

During its first year of operation, with one crew on duty from 9 a.m. to 5 p.m., Monday through Friday, the hospice’s savings averaged about $80 per trip, compared with the rates it had paid to other ambulance services. Currently, transport is offered 12 hours per day, 7 days per week. A second, used ambulance was recently purchased along with a wheelchair minivan.

The program has found its niche, Holmes says. It serves 95 percent of the hospice’s medical transport needs, averaging three and up to six trips per day. Currently, it employs four full-time and eight part-time or PRN EMTs. Five bays for the vehicles are located at the mobile care unit transportation hub in the basement of the hospice’s new Center for Supportive Care office building.

“Clearly, we’re still in the black with our mobile transport service. We can be more leanly staffed than a service that has to be ready to respond at a moment’s notice—and still meet our patients’ needs,” Holmes says. Potential future growth for the program includes expanding its geographic reach regionally and offering the service to other agencies, primarily other hospices, including those that are part of its nonprofit coalition, Ohio’s Hospice.

Not every hospice-enrolled patient needs an ambulance for transport, but it is used for those who have less mobility or can’t sit up, even in a wheelchair, for extended periods, says April Miller, an EMT for LifeCare. Hospice Hopes, a kind of miniature Make-A-Wish-type program, gives CareFirst patients an opportunity to experience—or re-experience—the world outside at a time when it would be hard for them to get into a car.

“We had a terminally ill patient who hadn’t been out of her house for months but wanted to take her teenaged son to see the new Top Gun movie,” Miller says. “We coordinated this with the theater and the patient’s hospice volunteer. We’ve taken patients to weddings and to church services. One couple wanted to celebrate their 62nd wedding anniversary at their favorite restaurant.”

Another patient, who was a steam engine enthusiast, was able to ride the ambulance to visit the historic 1876 train depot in Berea, Ohio, watch the trains, and then have lunch in the depot restaurant with a volunteer. “He got to make that trip twice before he passed away,” Miller says. “That means a lot to us. No matter how much comfort the hospice team is able to provide, we don’t often get to see that kind of enthusiasm.”

A patient’s granddaughter had told the hospice how much her grandmother liked milkshakes. “I said to her, ‘I’d love to take you out for a milkshake on your way home from your doctor’s visit.’ That just made her day,” Miller says. “It’s about the extra comfort we can offer through this program. If a patient looks scared, but isn’t saying anything, it’s likely that they are scared,” she says. “So I ask myself: What can I do to comfort them? It’s all about how we can relate to the patient and family at a more personal level.”

References

1. Wengler A, Potilechio M, Redinger K, et al. Care for a dying patient: EMS perspectives on caring for hospice patients. Journal of Pain and Symptom Management. 2022 Aug; 64(2): e71-e76.

2. Taigman M. Rescuing Hospice Patients. California Healthcare Foundation. December 20, 2016. Accessed via https://www.chcf.org/blog/rescuing-hospice-patients/#related-links-and-downloads

3. Fernandez A.R. Journal Watch: Can MIH Care Reduce Hospice Transports? EMS World, November 2021.

4. Accessed via https://www.amazon.com/Because-We-Care-Chaplaincy-Emergency-ebook/dp/B08ZV2B7X2.

Larry Beresford, a freelance health care writer based in Oakland, CA, writes about palliative care and hospital medicine for Medscape and the Quarterly Newsletter of the American Academy of Hospice and Palliative Medicine.