Development of a palliative paramedicine framework to standardise best practice: A Delphi study

Abstract

Background:

Growing global demand for palliative care services has prompted generalist clinicians to provide adjunct support to specialist teams. Paramedics are uniquely placed to respond to these patients in the community. However, embedding palliative care principles into their core business will require multifactorial interventions at structural, healthcare service and individual clinician and consumer levels.

Aim:

To develop a palliative paramedicine framework suitable for national implementation, to standardise best practice in Australia.

Design:

Delphi study utilising questionnaire completion; each round informed the need for, and content of, the next round. Free text comments were also sought in Round 1. Two rounds of Delphi were undertaken.

Setting/participants:

Sixty-eight participants took part in Round 1, representing six countries, and 66 in Round 2. Participants included paramedics, palliative care doctors and nurses, general practitioners, researchers and carers with lived experience and expertise in palliative paramedicine.

Results:

Seventeen of the original 24 components gained consensus; 6 components were modified; and 9 new components arose from Round 1. All modified and new components gained consensus in Round 2. Only one original component did not gain consensus across both rounds and was excluded from the final 32-component framework.

Conclusion:

This study has developed a comprehensive national framework addressing the macro-, meso- and micro-level interventions required to standardise palliative paramedicine across Australia. Future research ought to engage a multidisciplinary team to create an implementation strategy, addressing any perceived barriers, facilitators and challenges for applying the framework into policy and practice.

What is already known about the topic?

• When adequately trained and supported, paramedics can enhance person-centred care, reduce avoidable hospitalisations and facilitate the fulfilment of one’s preferred place of death.

• Embedding palliative and end-of-life care into paramedics’ core business will require multifactorial interventions at structural, healthcare service and individual clinician and consumer levels.

• The Delphi technique is a method of systematically collating expert consultation and building consensus. It is particularly useful for establishing frameworks in complex settings such as palliative paramedicine.

What this paper adds?

• This study gained consensus from an international multidisciplinary expert panel on 32 macro-, meso- and micro-level components of a palliative paramedicine framework, suitable for implementation to standardise practice at a national level.

• The expert panel called for stronger inclusion of bi-directional training and multidisciplinary debriefing opportunities between ambulance services and other palliative care providers.

Implications for practice, theory or policy?

• Our findings suggest paramedics should be supported to make complex clinical decisions specific to palliative care contexts with confidence and navigate holistic care pathways that prioritise referral functions available to other community-based clinicians.

• Future research should engage a multidisciplinary team to create an implementation strategy, which would reflect any perceived barriers, facilitators and challenges for applying the framework into policy and practice.

• In developing the implementation strategy, endorsement of relevant professional associations should be sought, a theory applied to guide next steps and the time and resources required to standardise palliative paramedicine practice across Australia acknowledged. Findings from testing the strategy could have resonance for palliative care providers and ambulance services worldwide.

Background

Growing global demand for palliative care services, and rising international preference for home-based deaths, ¹ have prompted an increasing number of generalist clinicians to provide adjunct palliative and end-of-life care support to specialist teams.^2–4 The COVID-19 pandemic accelerated this shift towards interdisciplinary palliative care, ⁵ highlighting the role primary care settings can play in this context. Paramedics already play an integral role in providing unscheduled care to patients in community-based settings worldwide. For example, a recent British retrospective cohort study analysed unscheduled and out-of-hours care for people in their last year of life, following patients as they pass from primary care to ambulance service, to emergency department, to finally being admitted into an in-patient ward. ⁶ The study identified that the extent of unscheduled care delivered to people in their last year of life, including by paramedics, is significantly greater and more varied than previously reported. The study’s authors concluded that managing more unscheduled care episodes in the community has the potential to reduce hospital admissions and overall costs. ⁶

Paramedics are uniquely placed to respond to palliative and end-of-life care patients in the community, particularly after-hours when specialist palliative care services might be unavailable. ⁷ When adequately trained and supported, paramedics can enhance person-centred care, reduce avoidable hospitalisations and facilitate the fulfilment of one’s preferred place of death.^1,8 However, attitudes towards expanding paramedics’ role to deliver palliative and end-of-life care in communities varies considerably within ambulance services, across health professions and throughout cultures.^9–12

Embedding palliative and end-of-life care into paramedics’ core business will require multifactorial interventions at structural, healthcare service and individual clinician and consumer levels. Previous studies have argued for greater inclusion of paramedicine in palliative care policies and frameworks; ¹⁰ discussed whether the role of palliative care ought to be relegated to specialist community paramedics;^13,14 identified the barriers to understanding and utilising advance care planning documentation in American pre-hospital settings; ¹⁵ explored Finnish paramedics’ palliative and end-of-life care clinical protocol and educational needs; ¹⁶ and investigated the essential elements to implementing a Canadian paramedic palliative model of care. ¹⁷ However, to our knowledge, no previous studies have outlined the strategies necessary to develop a comprehensive whole-of-system approach to palliative paramedicine.

The Delphi technique is a method of systematically collating expert consultation and building consensus. It is inherently constructivist in nature, and particularly useful for establishing frameworks in complex settings such as this one. ¹⁸ The aim of this study was to develop a palliative paramedicine framework suitable for national implementation, by determining the components considered most essential for improving the role of paramedics delivering palliative and end-of-life care in Australian communities. It is hoped the findings will shape a best practice framework suitable for national implementation.

Methods

Design

We employed a Delphi methodology to build systematic consensus from a broad range of experts, underpinned by a social constructivist epistemology. ¹⁸ This approach has previously been used in palliative care research to gather international perspectives and develop best practice guidelines and frameworks, especially when clinical trials and large-scale observational research were not possible.^18–21 The study adopted the four key methodological features of a Delphi: (1) a group of experts participated on a panel and were questioned about the issue of interest; (2) the process was anonymous to avoid conformity to a dominant view; (3) the procedure was iterative, comprising repeated rounds of enquiry and; (4) the design of subsequent rounds was informed by the summary of group responses from Round 1.^18,22 We adhered to the ‘Guidance on Conducting and REporting DElphi Studies’ (CREDES) to ensure robust methodology and reporting. ¹⁸

Setting

The focus of this Delphi study was paramedics delivering palliative and end-of-life care in community-based settings. An Anglo-American lens of ambulance services, where paramedics provide care to patients with medical oversight, was adopted throughout, in contrast to the Franco-German emergency physician-led model. ²³

Population

To broaden participation and encourage a wide range of international expertise, the target population to be recruited were healthcare professionals, academics and family carers with lived experience and significant expertise in palliative paramedicine in Australia and/or abroad. The healthcare professional and academic discipline sub-groups included paramedicine, palliative care, general practice and emergency medicine.

Sampling approach

We adopted a purposive, then snowballing approach to recruit participants who would become part of an expert panel. Firstly, potential health professional and academic participants were identified through their affiliation with the Australasian Palliative Paramedicine Advisory Group. This study-developed group was comprised of medical directors and senior clinical managers from all Australian and New Zealand ambulance services, and an experienced emergency nurse/palliative paramedicine researcher. We then approached health professional collegial networks with a targeted invitation, including the Australasian College of Paramedicine, Australasian College of Paramedicine Deans, Royal Australasian College of Physicians Chapter of Palliative Medicine, Palliative Care Nurses Australia and Royal Australian College of General Practitioners. International palliative paramedicine opinion leaders with publicly available email addresses were also invited to participate in the Delphi, as well as health professional and family carer participants of our previous study – a qualitative exploration of palliative paramedicine – who demonstrated strong interest and expertise in the topic. Then using a snowballing approach, all initial recipients of the Delphi invitation were also encouraged to forward the email to colleagues and affiliates they believed would be suitable and interested to participate in the study.

Recruitment

All potential participants were initially contacted by email and provided a participant consent form and information sheet, including a background on the topic, the purpose of the study, the intended Delphi process and contact details of the research team. Participants were invited to contact MJ via email to indicate they wished to take part.

Data collection

To gain consensus on which components should be included in a Palliative Paramedicine Framework (Framework), an online Delphi process was conducted using the Welphi platform, ²⁴ incorporating subsequent rounds of feedback until consensus was reached. Materials provided to the expert panel throughout the study, including the participant information statement and round questionnaires, were carefully reviewed and piloted by the research team, to examine understandability and balance. To maintain confidentiality, each participant was assigned a unique identifier which remained consistent throughout the Delphi rounds.

Original proposed framework components

Based on analysis of broader literature and the findings of our three previous studies,^{3,7,9,13,17,25,26} 24 original proposed Framework components were created by the research team for consideration by the expert panel. These components were categorised according to systems-based macro-level interventions, service and community-based meso-level interventions and individual clinician and consumer-based micro-level interventions.^27,28 This specific number and typology of components derived primarily from the findings of our previous qualitative study, which sought the attitudes, experiences and perspectives of clinicians and family carers with lived experience of palliative paramedicine. ⁹ A key finding arising from the study highlighted the need for any future framework to engage a multifactorial approach, thereby capturing the broad scope of components required to standardise practice and evoke sustainable change across the sector. ⁹ MJ drafted the original components and shared these with the research team for multiple rounds of discussion and refinement, before informal consensus was met and the team was satisfied to put these components to the expert panel in the round 1 questionnaire (Appendix 1).

Round 1 Delphi

A Round 1 Welphi link was sent to all registered participants via email in March 2023, and the questionnaire was open for 2 weeks. The participants completed a short demographic survey within this round to allow the sample to be described. The Round 1 questionnaire included 23 original components separated into three sections: macro-level; meso-level; and micro-level. Participants were asked to rate their level of agreement for each component to be included in the final Framework using a 5-point Likert scale: 1 – strongly disagree, 2 – disagree, 3 – neither agree nor disagree, 4 – agree, 5 – strongly agree. Free text comment boxes were also included after each component in this round, for participants to provide specific feedback and suggest modifications for consideration in Round 2. After each section, participants also had the opportunity to highlight anything that was missing and make suggestions for new components via free text comment boxes. The Delphi Round 1 questionnaire is available in Appendix 1.

Round 2 Delphi

A Round 2 Welphi link was sent to all Round 1 respondents in April 2023, and the questionnaire was open for 2 weeks. The Round 2 questionnaire included 16 original, new and modified components separated into the same three sections. During this round, participants were given the opportunity to revise their responses for any original components that did not reach consensus during round 1. The collective feedback of the expert panel from Round 1 was visible to participants for these original components to help guide their decision making. Participants were also asked to rate their level of agreement for the new and modified components arising from Round 1 feedback, using the same Likert scale. Participants were unable to provide feedback for any of the components via free text comments boxes during this round.

Data analysis

Percentages, median values and interquartile ranges (IQRs) were calculated for each component to describe the spread of answers. These values were then used to determine the level of agreement across the expert panel:^18,20

• Very high agreement: median = 5; percentage agreement ⩾80%; IQR 0

• High agreement: median = 4 or 5; percentage agreement ⩾80%; IQR 1

• Moderate agreement: median ⩽ 4; percentage agreement ⩾60%–79%; IQR ⩾1

• Low agreement: median < 4; percentage agreement <60%; IQR >1

An a priori criterion for consensus was defined by the research team as a component receiving ‘very high agreement’ or ‘high agreement’ from the expert panel. Those components that received these levels of agreement were retained for the Framework. Those components that received ‘low’ agreement were removed after one round. Those components that received ‘moderate’ agreement were presented to participants for further rounds of rating, after which if they still didn’t reach ‘high’ or ‘very high’ agreement, they would be removed from the Framework.

Round 1 Delphi

Descriptive statistics were automatically generated via the Welphi platform ²⁴ and cross-checked by MJ using Excel. ²⁹ Percentages, median values and IQRs were calculated for each Round 1 component to describe the spread of answers and determine the level of agreement across the panel. MJ qualitatively analysed the free text comments for each section, employing principles of content analysis ³⁰ to categorise feedback accordingly: (1) already addressed in existing component(s); (2) additional information constitutes a new component; and (3) could be used to modify, and thus enhance an existing component(s). MJ read all of the free text comments, familiarised herself with their content, independently identified potential new and modified components, and met with the team to discuss and develop these components. Consecutive dialogues facilitated multidisciplinary perspectives and allowed for consistent interpretation and classification of the feedback data into Round 2 components.

Round 2 Delphi

Percentages, median values and IQRs were again calculated for each Round 2 component to describe the spread of answers and determine the level of agreement across the panel. The a priori criterion for conducting a subsequent round was not met and, therefore, no further rounds were conducted.

Results

Participation

Of the 87 invited experts, 19 declined to participate due to too many other commitments and/or a self-perceived lack of expertise in the area to contribute meaningfully to the Delphi. Sixty-eight participants took part in Round 1, representing six countries and all jurisdictions of Australia, while 66 participants took part in Round 2, representing the same six countries. Table 1 shows demographic and professional characteristics of participants across the two rounds of the Delphi. In Round 1 and 2, 37% and 38% of the expert panel were aged between 45 and 54 years, respectively, 65% and 62% were female, respectively, 44% had a palliative care background and 59% had more than 20 years experience in their profession.

Table 1.

Descriptive characteristics of participants.

All participant characteristics	Round 1	Round 2
	Participants (%)	Participants (%)
	N = 68	N = 66
Age (years)
18–24	0 (0)	0 (0)
25–34	4 (6)	4 (6)
35–44	16 (24)	15 (23)
45–54	25 (37)	25 (38)
55–64	19 (28)	18 (27)
65+	4 (6)	4 (6)
Gender
Male	24 (35)	24 (36)
Female	44 (65)	42 (62)
Non-binary	0 (0)	0 (0)
Australian first nations identifying
Aboriginal	1 (1)	1 (2)
Torres Strait Islander	0 (0)	0 (0)
Both	1 (1)	1 (2)
Neither	65 (96)	63 (95)
Prefer not to say	1 (1)	1 (2)
Country of birth
Australia	48 (71)	46 (70)
Canada	1 (1)	1 (2)
Finland	1 (1)	1 (2)
Germany	1 (1)	1 (2)
Hong Kong	1 (1)	1 (2)
Kenya	1 (1)	1 (2)
Netherlands	1 (1)	1 (2)
New Zealand	2 (3)	2 (3)
Papua New Guinea	1 (1)	1 (2)
Republic of Korea	1 (1)	1 (2)
Singapore	1 (1)	1 (2)
United Kingdom	8 (12)	8 (12)
United States of America	1 (1)	1 (2)
Country of residence
Australia	61 (90)	59 (89)
Canada	1 (1)	1 (1)
Finland	1 (1)	1 (1)
New Zealand	2 (3)	2 (3)
South Africa	1 (1)	1 (1)
United Kingdom	2 (3)	2 (3)
Employment status
Full time	56 (82)	55 (83)
Part time or causal	10 (15)	9 (14)
Retired	2 (3)	2 (3)
Professional background
Emergency medicine	2 (3)	2 (3)
General practice	5 (7)	5 (8)
Palliative care	30 (44)	29 (44)
Paramedicine	27 (40)	26 (39)
Family member/carer	4 (6)	4 (6)
Professional role
Emergency nurse/academic	1 (1)	1 (2)
Emergency doctor/academic	1 (1)	1 (2)
GP	2 (3)	2 (3)
GP/academic	2 (3)	2 (3)
GP/service manager	1 (1)	1 (2)
Palliative care academic	5 (7)	5 (8)
Palliative care doctor	6 (9)	5 (8)
Palliative care doctor/academic	1 (1)	1 (2)
Palliative care nurse	12 (18)	12 (18)
Palliative care nurse/academic	2 (3)	2 (3)
Palliative care nurse/service manager	3 (4)	3 (5)
Paramedic	8 (12)	8 (12)
Paramedic/academic	12 (18)	12 (18)
Paramedic/service manager	8 (12)	7 (11)
Family member/carer	4 (6)	4 (6)
Years in profession
Less than 1	0 (0)	0 (0)
1–5	1 (1)	1 (2)
6–9	3 (4)	3 (5)
10–19	24 (35)	23 (35)
20+	40 (59)	39 (59)
Education background
Completed high/secondary school	1 (1)	1 (2)
Completed high/secondary school to year 10	0 (0)	0 (0)
Completed final year high/secondary school	0 (0)	0 (0)
Professional certificate or vocational school (Diploma)	2 (3)	2 (3)
Undergraduate degree (Bachelor)	12 (18)	11 (17)
Postgraduate degree (Master/MD/PhD)	53 (78)	52 (79)
Jurisdiction
Australian Capital Territory	3 (4)	3 (5)
New South Wales	16 (24)	16 (24)
Northern Territory	2 (3)	1 (2)
Queensland	14 (21)	14 (21)
South Australia	6 (9)	6 (9)
Tasmania	2 (3)	1 (2)
Victoria	16 (24)	16 (24)
Western Australia	2 (3)	2 (3)
International	7 (10)	7 (11)

Percentages rounded to nearest whole number.

Round 1 Delphi

Seventeen of the original components from Round 1 gained consensus: and were included in the final Framework, as depicted in Figure 1 and Table 3. Six original components gained consensus; however, considering feedback from the expert panel, modifications were made to enhance each of these components for participants to reconsider in Round 2. Nine new components arose from Round 1 feedback: three macro-level, four meso-level and two micro-level. Only one original component did not reach consensus in Round 1: Include a routine question within an ambulance call taker’s algorithm that prompts further questioning about a patient’s palliative care status and notify paramedics before they arrive on scene. This component remained unmodified, for participants to reconsider in Round 2. Table 2 highlights the expert panel feedback from Round 1, including the experts panel’s comments for the component that did not reach consensus, as well as the modified and new components.

Figure 1.

Flowchart of Delphi process.

Table 3.

Levels of agreement for components in Round 1.

Component	Median score (1–5) 1 – Strongly disagree 2 – Disagree 3 – Neither agree nor disagree 4 – Agree 5 – Strongly agree	IQR	% agree/strongly agree	Level of agreement	Achieved consensus (80% or more agree/strongly agree)
Macro 1: Include paramedicine in national and jurisdictional palliative and end-of-life care policies and frameworks.	5	0	100	Very high	Yes
Macro 2: Include paramedicine in interdisciplinary palliative and end-of-life care policies and frameworks.	5	1	100	High	Yes
Macro 3: Provide paramedic services access to electronic medical records, enabling paramedics to access patients’ advance care planning and palliative care details in real time.	5	0	96	Very high	Yes
Macro 4: Develop and implement State/Territory specific documentation for patients, families and/or carers to complete alongside their healthcare team/s to allow paramedics to rapidly identify a patient’s palliative and end-of-life goals of care. Ensure processes for the documentation to be uploaded and accessible electronically.	5	1	90	High	Yes
Macro 5: Broaden paramedic scope of practice to verify death on scene where appropriate.	5	1	89	High	Yes
Macro 6: Embed palliative care into all paramedicine undergraduate and postgraduate curriculum, including theoretical and practical components.	5	0	98	Very high	Yes
Macro 7: Acknowledge and broaden the paramedicine profession to include clinical roles beyond an ambulance setting that is, paramedics with enhanced palliative care capabilities in primary care settings.	5	1	82	High	Yes
Meso 11: Promote healthcare services to recognise the paramedic scope of practice includes palliative and end-of-life care skills.	5	1	97	High	Yes
Meso 12: Require all ambulance services to maintain a best practice palliative and end-of-life care guideline, including verification of death processes.	5	1	95	High	Yes *Modified for Round 2 according to Round 1 feedback
Meso 13: Include a routine question within an ambulance call taker’s algorithm that prompts further questioning about a patient’s palliative care status and notify paramedics before they arrive on scene.	4	1	75	Moderate	No *Put forward in original form for round 2
Meso 14: Standardise paramedic palliative and end-of-life care education and training, including building capacity for paramedics to verify death.	5	1	99	High	Yes *Modified for Round 2 according to Round 1 feedback
Meso 15: Provide specialist training pathways for paramedics expressing interest and capacity in palliative and end-of-life care.	5	1	87	High	Yes
Meso 16: Incorporate and connect paramedics to localised palliative care referral pathways, including alternative referral destinations beyond an Emergency Department.	5	0	96	Very high	Yes
Meso 17: Establish interprofessional understanding between ambulance services and palliative care, aged care and general practice services through localised networks.	5	1	99	High	Yes *Modified for Round 2 according to Round 1 feedback
Meso 18: Develop public health palliative care campaigns to educate health professionals and the public on a paramedic’s role in delivering community-based palliative and end-of-life care.	5	1	85	High	Yes *Modified for Round 2 according to Round 1 feedback
Micro 23: Mandate generalist palliative care capabilities for all paramedics.	4	1	83	High	Yes
Micro 24: Create optional specialist palliative care capabilities for interested and willing paramedics to pursue.	5	1	81	High	Yes
Micro 25: Identify and support interested and willing paramedics to become palliative care champions within their respective workplace. Connect these clinicians with local grass roots palliative care initiatives.	5	1	94	High	Yes
Micro 26: Equip paramedics with communication skills to engage patients, families and carers to partner in palliative and end-of-life care through shared decision-making and debriefing.	5	1	96	High	Yes *Modified for Round 2 according to Round 1 feedback
Micro 27: Equip paramedics with resources to refer patients, families and/or carers palliative care supportive services.	5	1	91	High	Yes
Micro 28: Instil family-centred and culturally appropriate care after death principles into paramedic palliative and end-of-life care practice.	5	1	94	High	Yes *Modified for Round 2 according to Round 1 feedback
Micro 29: Provide paramedics access to self-care and peer support services, including debriefing opportunities for unexpected and expected deaths.	5	1	96	High	Yes
Micro 30: Equip patients, families and carers with appropriate state/territory advance care planning documentation to share with paramedics upon arrival, to allow for the rapid identification of the patient’s palliative and end-of-life goals of care.	5	1	91	High	Yes
Micro 31: Educate families and carers to provide paramedics with contact details of patient’s healthcare providers, including GP and specialist palliative care services.	5	1	88	High	Yes

Table 2.

Modifications and additions to Round 2 following free text comments from Round 1.

General comments received in Round 1
• There needs to be paramedic standards and national paramedic clinical practice guidelines related to palliative care. (Paramedic and academic, ID15) • Quality performance/indicators and outcomes designed between patient/carers palliative care and paramedicine sectors. (Palliative care doctor, ID55) • A corresponding national suite of measures to monitor and improve the quality of paramedicine palliative care. (Paramedic and academic, ID16) • Include palliative paramedicine in workforce planning. (Palliative care doctor, ID13) • Ensure paramedic services have policies which are internally consistent, addressing expected death, non-transport, palliative care pathways. (Emergency doctor and academic, ID24) • A recognised advanced communication education which includes ‘breaking bad news’ for all clinicians both as undergraduates and post-graduates. (Palliative care nurse and academic, ID26) • Standardised training and accreditation/reaccreditation requirements for palliative care trained paramedics. (Paramedic, ID49) • Extra training for our current paramedic workforce in Palliative Care in all aspects (referrals, treatments, medications, goals of care). (Paramedic and service manager, ID64) • Consider opportunities for community palliative care clinicians and paramedics to provide education to each other. (Palliative care nurse, ID66) • Paramedic exposure through opportunities to work in hospices. (Paramedic and service manager, ID1) • Is there any training in nursing education re paramedics’ role? Paramedics must have a placement in community nursing and palliative care settings as an undergraduate. This would build relationships in the long term. It would also be of benefit if nursing students have a placement with paramedics. (Palliative care nurse, ID59) • At a macro level, it would be good to engage with the current developments around community paramedicine, to allow for a substantial role embedded in a multidisciplinary framework. (Palliative care researcher, ID60) • Interprofessional education should form part of curriculum development throughout paramedicine degrees. This will allow students to develop industry links whilst studying and create a better understanding of the roles each department plays when attending the palliative patient. (Paramedic and academic, ID43) • Ensure ongoing interdisciplinary advisory or stakeholder council meetings to facilitate knowledge exchange around best practice, local care pathways, mutually supportive team approach. (Emergency doctor and academic, ID24) • Multidisciplinary training with GPs to increase understanding and ability to work professionally together. (GP, ID46) • Role of specialist palliative care services in provision of ongoing education to paramedics and collaboration around the changes within Palliative care. (Palliative care nurse, ID58) • Establish a program where for example, a community palliative care nurse would spend allocated time with paramedics, and vice versa. (Paramedic and academic, ID38) • Paramedic exposure through opportunities to work in hospices. (Paramedic and service manager, ID1) • Ensure ongoing inter-disciplinary advisory or stakeholder council meetings to facilitate knowledge exchange around best practice, local care pathways, mutually supportive team approach. (Emergency doctor and academic, ID24) • Training (tertiary ed or in-house or VET) that sees palliative care delivered by a paramedic as core business that is, via a registered (qualified) paramedic or referral by a qualified paramedic to other care providers, including specialist paramedics. (Paramedic and academic, ID38) • ‘Story telling’ between services of memorable experiences – good or otherwise – can be a significant learning tool in educating each other. (Palliative care nurse, 66) • Paramedic & GP access to point of care clinical support with palliative care specialists – provided by Local Health Districts who oversee patient care. (Paramedic and service manager, ID18) • Work towards direct contacts between services and local Paramedics, with regular debriefing and reflection. (Palliative care nurse, 66) • Development of a centralised support resource (paramedic with specific palliative care training) to support the work of paramedics and ambulance officers on the ground, particularly in regional, rural and remote areas in dealing with palliative and end-of-life care clinical situations, A resource with understanding across both the acute paramedic services, and the palliative and end-of-life care space to help facilitate clinical-decision-making in complex end-of-life care cases. (Palliative care doctor, ID11) • Formal linkages with specialist palliative care providers. (Palliative care nurse and service manager, ID53) • Ensure systems of support to paramedics for example, where paramedics are at scene with a palliative care patients that the paramedics can easily obtain appropriate palliative medicine/ care support for example, through specialist palliative care or primary care physician who knows the patient. Also need to ensure there is a system of the paramedics handing over care to others when the patient is not transferred into hospital. (Palliative care doctor and academic, ID28) • A forum for a regular handover from local palliative care services to local Paramedic services regarding any potential clients and having the ability for those to be flagged within paramedics. (Palliative care nurse, ID58)
General comments received in Round 1
• Death reviews, complex case meetings and debriefing support within local palliative care multidisciplinary team meetings, occurring in both acute and community settings, to improve communication, insights and collegiality. (Palliative care doctor, ID55) • There is a shortage of advanced paramedics in rural and remote areas. These are the areas that really struggle with support out of hours and on weekends which leads to hospital admissions. I think ensuring access to these types of services in rural and remote areas needs to be written into the framework. (Palliative care nurse, ID2) • Identify areas where after hours support is limited and liaise directly with the Paramedic service locally to provide information and support to the person requiring care. (Palliative care nurse, ID66) • Need to be really careful to bolster what already exists for palliative care in the community and that ambulance services are a useful backup service for symptom management and verification of death outside of hours when other support is not readily available. (Paramedic and researcher, ID6) • Acknowledgement of cultural differences and no single one right way to approach death and dying. Responsibilities to Indigenous Australians and acknowledgement that minority groups have increased risk of poor outcomes and are less likely to access specialised palliative care. (Emergency nurse and academic, ID22) • Education to chronic disease, and community-controlled healthcare organisations, Aboriginal health workers or liaisons should be included in the team approach as a valuable source of support for paramedics to call on for any Indigenous patients. (Palliative care nurse and service manager, ID30) • Provision of suitable available medications to Paramedics to support EOLC in urgent circumstances where systems of support have not yet been identified. (Paramedic and service manager, ID45) • Policies for paramedics to administer ‘break through’ medications without the need to transport. For example, currently it is standard procedure for all patients who have had opioids to be transported for observation. (Paramedic and service manager, ID1) • A national ‘Authorised care plan’ document that can allow standard paramedics to provide symptom management that may be outside of their scope using these care plans, which are written and authorised by a GP, nurse practitioner or other specialist. (Paramedic and academic, ID6) • Possible option for paramedics to commence, contribute or add additional notes to ‘care plan’ – even if it is simply that a conversation was commenced and request to flag for further discussion with a palliative care team. (Paramedic, ID32) • Palliative and end-of-life care planning with the person and their family should incorporate the use of paramedics so that it is clear from the outset that they are part of the care model, clearly identifying their role would be important. (Palliative care nurse, ID2) • Equip paramedics to navigate family conflict around goals of care. Awareness of oncologic emergencies and nuanced scenarios in which transport is appropriate. (Emergency doctor and academic, ID24) • Funding research which seeks to understand what patients and families experience and need from paramedics at the end of life. (Emergency nurse and academic, ID22) • Part of high-quality palliative and end of life care is awareness of the law that governs and supports paramedic practice. This is something which I would suggest including. (Palliative care researcher, ID34) • I think there also need to be consultation with various consumer groups, those who relate to end of life issues, such as disease-based groups and consumer health forums. (Paramedic and academic, ID61) • Develop an education campaign to improve GP knowledge and practice around community death. Many of the verification of death challenges are due to GPs not understanding the paramedic role in verifying death, and funeral directors not having a standardised approach. This leads to inappropriate utilisation of resources (such as police) and prolonged grief for family and carers due to coronial referral. (Paramedic and service manager, ID18) • Education is important and having a standard platform for all of Australia would make things easier, especially when a patient may live in a border town. A campaign needs to be conducted to inform all players in health care about the role of a paramedic in palliative care and about palliative care in general. (Family carer, ID51) • Ensure that at all stages the role of promoting death, grief and bereavement literacy is included. (GP, ID9)
Comments received in Round 1 for component 13 (did not reach consensus)
• This is bigger than just adjusting the requirements of call takers. These algorithms they follow are based on international best practice and would require collaboration with the organisation that holds the certification that all ambulance services must have, in order to remain certified. Great idea for moving forward and it needs to occur, however if adjusting the algorithm, it is a much bigger process. Maybe directing these calls to secondary triage is a better option, as this is already in place and those answering secondary triage calls have a freedom to ask these additional questions in a way that call takers do not. (Paramedic academic, ID37) • This can prevent the wrong resource being sent to the patient and ensures the patient receives timely care with the right clinical level attending. (Paramedic academic, ID43) • This could be risky. If interpreted incorrectly by a non-medical call-taker, this could result in a diversion of an ambulance. It also could be seen as sterile and insensitive when scripted. (Palliative care nurse, ID44) • Unsure about this one – we’d have to be sure the questions had good sensitivity and specificity and that seems quite challenging. (Palliative care nurse, ID22)
Comments received in Round 1 for component 13 (did not reach consensus)
• Not sure this is necessary. The public have a hard enough time currently working out what to call an ambulance for and what not. If they called their GP/palliative care specialist who then identified, they would benefit from a paramedic that would result in more appropriate taskings. Palliative care nurses write in the in-home books ‘any problems, call an Extended Care Paramedic’ which annoys their own doctors because the patients call 000 when they would have benefited more from calling the doctor at times. (Paramedic, ID47) • Currently there is no AMPDS/ProQA determinant for patients at end of life, hence these cases are dispatched as a confused jumble of pain/shortness of breath/bleeding/collapse usually with an under lights response as the severity/acuity is detected during call handling. The problem is that this ‘under-lights emergency’ momentum often carries through and results in inappropriate, undignified, futile and unpleasant resuscitation and/or transport. (Paramedic, ID28) • Dispatch staff often have to make a decision to sort patients into ‘resuscitation’ responses and ‘end-of-life care’ responses. An incorrect decision around the ‘sorting’ process will have significant detrimental consequences (regardless of whether a resuscitation scenario is mis-identified as ‘end-of-life’ care, or vice versa). Any decision-making support to minimise error is very important. (Palliative care doctor, ID11) • I suspect from a practical point of view this would be unworkable. Most services in Australia and New Zealand use AMPDS and the call taking scripts are fairly rigid and hard to change. In addition, I suspect it would be quite confronting for callers. There may a subset of patients in whom it could have some value though. (Palliative care doctor, ID54) • And advance care plan status, is there one? Just because someone is under palliative care, it does not mean they are not for resus or aggressive treatment of reversible symptoms at times. (Palliative care nurse, ID31) • This is so important for correct dispatch, and appropriate response and dignity for the family. (Palliative care nurse, ID65) • I am not certain if this should be routine. I feel this should be something that is prompted by the content of the call. I suspect many ambulance calls will not be related to palliative care or end of life care, so routine questioning may not be appropriate. (Palliative care doctor, ID19) • Care must be taken as a ‘palliative care status’ could be stigmatising and or prejudicial to care. It has nuances – when stratified into palliative approach (where it is appropriate to attend hospital to have investigations and reversible things reversed that is, infections, hypercalcaemia, toxic AEs of treatment); end of life care where goal is to stay at home for as long as possible but things may change quickly requiring a rapid reorientation of goals; terminal care where patient is imminently dying and attendance may be determined to assist with symptom control or transfer to preferred place of death: in some cases hospital or palliative care unit. (Palliative care doctor, ID55) • This is a system that can cause carer/ family distress when calling triple 000 for a loved one who was an expected death. This is currently an issue with our dispatch system. Not only will this assist in delivering the most appropriate response and resource to be sent to complete a verification of death certificate when community-based palliative care services are not available/ GP (after hours, public holidays, etc). (Paramedic, ID64) • I think this has the potential to introduce bias into the patient approach. (Paramedic, ID3) • The general public often struggle with the word palliative care and consider this to be terminal, not life limiting. This could provide inaccurate information prior to arriving where the patient is. (Palliative care nurse, ID59) • I think this may be appropriate but would need careful triggers. Do we want to know about palliative care status for the young person with a fractured tibia? (Palliative care academic, ID5) • Ideally, I would recommend this is asked at the call taker end and not the secondary/ambulance internal triage end. We continue to see episodes where police, fire and ambulance services are called out as a CAT 0 priority to attend to an expected death. This is often a distressing event for all involved. If it could be readily recognised when there is a call for a palliative patient and an expected death that would improve the system greatly. (Palliative care nurse, ID63)
Macro-level
Original component (Round 1)	Modified component (Round 2)
New components (Round 2)
8. Develop palliative paramedicine quality performance indicators and outcomes through a co-design process between consumers, palliative care and paramedicine sectors. 9. Include paramedicine in workforce planning for palliative and end-of-life care. 10. Ensure equitable access to paramedics providing palliative and end-of-life care for consumers in all geographical settings, including metropolitan, regional, rural and remote areas.
Meso-level
Original component (Round 1)	Modified component (Round 2) – changes in bold
12. Require all ambulance services to maintain a best practice palliative and end-of-life care guideline, including verification of death processes.	12. Require all ambulance services to maintain a best practice palliative and end-of-life care guideline, including the ability to deliver specific sub-cutaneous medications for common end-of-life symptoms without transport, and verification of death processes.
14. Standardise paramedic palliative and end-of-life care education and training, including building capacity for paramedics to verify death.	14. Standardise paramedic palliative and end-of-life care education and training, including building capacity for paramedics to navigate end-of-life law and verify death.
17. Establish interprofessional understanding between ambulance services and palliative care, aged care and general practice services through localised networks.	17. Establish interprofessional linkages and understanding between ambulance services and palliative care, aged care and general practice services through localised networks, bi-directional training and routine multidisciplinary debriefing opportunities.
18. Develop public health palliative care campaigns to educate health professionals and the public on a paramedic’s role in delivering community-based palliative and end-of-life care.	18. Develop public health palliative care campaigns to educate health professionals and the public on a paramedic’s role in delivering community-based palliative and end-of-life care, including verification of death where required.
New components (Round 2)
19. Require state and territory palliative care plans to include recommendations for how clinical palliative care back-up support at the point of care will be provided to paramedics within local health jurisdictions. 20. Facilitate the collaboration between state/territory representative palliative care organisations and ambulance services to map the after-hours community-based palliative care service gaps within their respective jurisdictions, to promote needs-based investments of palliative paramedicine and avoid duplication of services. 21. Require state and territory palliative care plans to include recommendations for local health jurisdictions to develop systems to enable paramedics to rapidly identify an individual patient’s current palliative care medications and breakthrough doses. 22. Ambulance services to mandate a process for paramedics to complete an electronic (or paper copy) handover upon treating a palliative care patient who is not transferred and remains at home, for other healthcare services to access to promote continuity of care.
Micro-level
Original component (Round 1)	Modified component (Round 2) – changes in bold
26. Equip paramedics with communication skills to engage patients, families and carers to partner in palliative and end-of-life care through shared decision-making and debriefing.	26. Equip paramedics with communication skills about death and dying to provide support and engage patients, families and carers to partner in palliative and end-of-life care through shared decision-making and debriefing.
28. Instil family-centred and culturally appropriate care after death principles into paramedic palliative and end-of-life care practice.	28. Instil family-centred and culturally appropriate care leading up to and after death principles into paramedic palliative and end-of-life care practice.
New components (Round 2)
32. Educate families and carers about the role of paramedics in the provision of their palliative care, and when it is helpful to call an ambulance. 33. Equip paramedics with resources to provide families and/or carers with information about care after death, grief and bereavement.

Round 2 Delphi

The six modified components and nine new components arising from Round 1, gained consensus in Round 2 and were included in the Framework. The remaining original component failed to gain consensus in Round 2, reducing its consensus score from 75% agree/strongly agree (median 4, IQR 1) in Round 1, to 72% (median 4, IQR 2) in Round 2. These results rendered the exclusion of the component from the Framework. Given all components had now either reached consensus or been removed, no further rounds of Delphi were required. Table 4 highlights the results from Round 2, and Table 5 illustrates the final components of the Framework.

Table 4.

Levels of agreement for original, modified and additional components in Round 2.

Component Bold text – modified component Italic text – new component	Median score (1–5) 1 – Strongly disagree 2 – Disagree 3 – Neither agree nor disagree 4 – Agree 5 – Strongly agree	IQR	% agree/strongly agree	Level of agreement	Achieved consensus (80% or more agree/strongly agree)
Macro 8. Develop palliative paramedicine quality performance indicators and outcomes through a co-design process between consumers, palliative care and paramedicine sectors.	5	1	96	High	Yes
Macro 9. Include paramedicine in workforce planning for palliative and end-of-life care.	5	1	92	High	Yes
Macro 10. Ensure equitable access to paramedics providing palliative and end-of-life care for consumers in all geographical settings, including metropolitan, regional, rural and remote areas.	5	1	86	High	Yes
Meso 12: Require all ambulance services to maintain a best practice palliative and end-of-life care guideline, including the ability to deliver specific sub-cutaneous medications for common end-of-life symptoms without transport, and verification of death processes.	5	1	98	High	Yes *Improved from 95% in Round 1
Meso 13: Include a routine question within an ambulance call taker’s algorithm that prompts further questioning about a patient’s palliative care status and notify paramedics before they arrive on scene.	4	2	72	Moderate	No *Failed to achieve consensus in Round 1 and 2, therefore removed from the framework
Meso 14: Standardise paramedic palliative and end-of-life care education and training, including building capacity for paramedics to navigate end-of-life law and verify death.	5	1	94	High	Yes *Reduced from 99% in Round 1
Meso 17: Establish interprofessional linkages and understanding between ambulance services and palliative care, aged care and general practice services through localised networks, bi-directional training and routine multidisciplinary debriefing opportunities.	5	1	99	High	Yes *Remained the same as Round 1
Meso 18: Develop public health palliative care campaigns to educate health professionals and the public on a paramedic’s role in delivering community-based palliative and end-of-life care, including verification of death where required.	4	1	83	High	Yes *Reduced from 85% in Round 1
Meso 19: Require state and territory palliative care plans to include recommendations for how clinical palliative care back-up support at the point of care will be provided to paramedics within local health jurisdictions.	5	1	91	High	Yes
Meso 20: Facilitate the collaboration between state/territory representative palliative care organisations and ambulance services to map the after-hours community-based palliative care service gaps within their respective jurisdictions, to promote needs-based investments of palliative paramedicine and avoid duplication of services.	5	1	92	High	Yes
Meso 21: Require state and territory palliative care plans to include recommendations for local health jurisdictions to develop systems to enable paramedics to rapidly identify an individual patient’s current palliative care medications and breakthrough doses.	5	1	91	High	Yes
Meso 22: Ambulance services to mandate a process for paramedics to complete an electronic (or paper copy) handover upon treating a palliative care patient who is not transferred and remains at home, for other healthcare services to access to promote continuity of care.	5	1	97	High	Yes
Micro 26: Equip paramedics with communication skills about death and dying to provide support and engage patients, families and carers to partner in palliative and end-of-life care through shared decision-making and debriefing.	5	0	98	Very high	Yes *Improved from 96% in Round 1
Micro 28: Instil family-centred and culturally appropriate care leading up to and after death principles into paramedic palliative and end-of-life care practice.	5	1	97	High	Yes *Improved from 94% in Round 1
Micro 32: Educate families and carers about the role of paramedics in the provision of their palliative care, and when it is helpful to call an ambulance.	5	1	94	High	Yes
Micro 33: Equip paramedics with resources to provide families and/or carers with information about care after death, grief and bereavement.	5	1	89	High	Yes

Table 5.

Final framework components.

Level	Component
Macro	Include paramedicine in national and jurisdictional palliative and end-of-life care policies and frameworks.
	Include paramedicine in interdisciplinary palliative and end-of-life care policies and frameworks.
	Provide paramedic services access to electronic medical records, enabling paramedics to access patients’ advance care planning and palliative care details in real time.
	Develop and implement State/Territory specific documentation for patients, families and/or carers to complete alongside their healthcare team/s to allow paramedics to rapidly identify a patient’s palliative and end-of-life goals of care. Ensure processes for the documentation to be uploaded and accessible electronically.
	Broaden paramedic scope of practice to verify death on scene where appropriate.
	Embed palliative care into all paramedicine undergraduate and postgraduate curriculum, including theoretical and practical components.
	Acknowledge and broaden the paramedicine profession to include clinical roles beyond an ambulance setting that is, paramedics with enhanced palliative care capabilities in primary care settings.
	Develop palliative paramedicine quality performance indicators and outcomes through a co-design process between consumers, palliative care and paramedicine sectors.
	Include paramedicine in workforce planning for palliative and end-of-life care.
	Ensure equitable access to paramedics providing palliative and end-of-life care for consumers in all geographical settings, including metropolitan, regional, rural and remote areas.
Meso	Promote healthcare services to recognise the paramedic scope of practice includes palliative and end-of-life care skills.
	Require all ambulance services to maintain a best practice palliative and end-of-life care guideline, including the ability to deliver specific sub-cutaneous medications for common end-of-life symptoms without transport, and verification of death processes.
	Standardise paramedic palliative and end-of-life care education and training, including building capacity for paramedics to navigate end-of-life law and verify death.
	Provide specialist training pathways for paramedics expressing interest and capacity in palliative and end-of-life care.
	Incorporate and connect paramedics to localised palliative care referral pathways, including alternative referral destinations beyond an Emergency Department.
	Establish interprofessional linkages and understanding between ambulance services and palliative care, aged care and general practice services through localised networks, bi-directional training and routine multidisciplinary debriefing opportunities.
	Develop public health palliative care campaigns to educate health professionals and the public on a paramedic’s role in delivering community-based palliative and end-of-life care, including verification of death where required.
	Require state and territory palliative care plans to include recommendations for how clinical palliative care back-up support at the point of care will be provided to paramedics within local health jurisdictions.
	Facilitate the collaboration between state/territory representative palliative care organisations and ambulance services to map the after-hours community-based palliative care service gaps within their respective jurisdictions, to promote needs-based investments of palliative paramedicine and avoid duplication of services.
	Require state and territory palliative care plans to include recommendations for local health jurisdictions to develop systems to enable paramedics to rapidly identify an individual patient’s current palliative care medications and breakthrough doses.
	Ambulance services to mandate a process for paramedics to complete an electronic (or paper copy) handover upon treating a palliative care patient who is not transferred and remains at home, for other healthcare services to access to promote continuity of care.
Micro	Mandate generalist palliative care capabilities for all paramedics.
	Create optional specialist palliative care capabilities for interested and willing paramedics to pursue.
	Identify and support interested and willing paramedics to become palliative care champions within their respective workplace. Connect these clinicians with local grass roots palliative care initiatives.
	Equip paramedics with communication skills about death and dying to provide support and engage patients, families and carers to partner in palliative and end-of-life care through shared decision-making and debriefing.
	Equip paramedics with resources to refer patients, families and/or carers palliative care supportive services.
	Instil family-centred and culturally appropriate care leading up to and after death principles into paramedic palliative and end-of-life care practice.
	Provide paramedics access to self-care and peer support services, including debriefing opportunities for unexpected and expected deaths.
	Equip patients, families and carers with appropriate state/territory advance care planning documentation to share with paramedics upon arrival, to allow for the rapid identification of the patient’s palliative and end-of-life goals of care.
	Educate families and carers to provide paramedics with contact details of patient’s healthcare providers, including GP and specialist palliative care services.
	Educate families and carers about the role of paramedics in the provision of their palliative care, and when it is helpful to call an ambulance.
	Equip paramedics with resources to provide families and/or carers with information about care after death, grief and bereavement.

Discussion

Main findings from the study

Paramedic provision of palliative and end-of-life care is an emerging frontier for the discipline globally, with significant potential to assist other palliative care services, specialist and generalist alike, in their provision of care.^3,11 However, standardising best-practice to optimise the role paramedics can play requires a multifactorial approach ⁹ and geographical nuance, especially in a country as large and diverse as Australia. ¹³ This study allowed a group of international multidisciplinary experts the chance to deliberate the best available evidence, employing their experiential expertise to achieve consensus on a comprehensive range of 10 macro-, 11 meso- and 11 micro-level components for inclusion in the final Framework, suitable for national implementation. Australians were the largest participant pool of the sample, but international experts were added to provide a wider perspective and increase the likelihood the Framework could be relevant in other comparable health systems. The components included structural, healthcare service, community, clinician and consumer-level interventions.

Items included in the framework

Perhaps most prominent amongst the experts’ first round of feedback was the demand for stronger inclusion of bi-directional training and multidisciplinary debriefing opportunities between ambulance services and other palliative care providers, as reflected by our modification to meso 17 in Round 2. These findings are supported by Canadian and American models of palliative paramedicine practice, which substantiate the power of formalising communication and education channels between paramedics and palliative care clinicians.^17,31 By requiring each jurisdiction to establish training and debriefing networks between ambulance services and local palliative care providers (including GPs and aged care), mutual understanding of capacities, strengths and weaknesses could be fostered, leading to greater awareness of interdisciplinary palliative care capabilities and a reduction in siloed care.

To continue challenging the curative treatment and transport orthodoxy of ambulance services worldwide, paramedics need to be supported to make complex clinical decisions with confidence, and navigate holistic care pathways that prioritise referral functions available to other community-based clinicians.^9,13 Another omission from our original components, as identified by the expert panels’ feedback and new meso-level component 19, was the need for clinical back-up support pathways for paramedics at the point of care. Our authorship team assumed this would already occur in a generalist sense, without articulating it in the Australian context, as some jurisdictions already have these processes in place. However, the Round 1 feedback indicated the expert panel considered specialist palliative care support a desirable Framework component, even if only available via telehealth. This is consistent with the findings of a German study, where emergency medical services personnel perceived paediatric palliative care emergencies to be particularly stressful, and requested a local palliative care contact be available 24/7 to provide clinical guidance and backup where necessary. ³² Furthermore, a Canadian study highlighted the utility of patients with a life-limiting illness being enrolled into a novel treat and refer palliative paramedicine clinical pathway. In sixty-eight percent of cases where this pathway was in place, paramedics engaged in a remote clinical consultation to facilitate care in the home, demonstrating how imperative clinical support can be in mitigating risk and reducing unnecessary conveyance to hospital. ¹ In conjunction with formalising training and debriefing opportunities between ambulance services and other palliative care providers, ensuring Australian paramedics have a round-the-clock phone number to call for specialist palliative care clinical support will be an integral step towards incorporating paramedicine into the multidisciplinary palliative care landscape.

The only component to not gain consensus across both rounds pertained to modifying ambulance services’ call algorithms to prompt further questioning about a patient’s palliative care status and notify paramedics when they arrive on scene. While suggested by participants in our previous research to help with triaging, some of the expert panel commented this could be risky strategy and challenging to implement, as detailed in Table 2. Some common justifications provided by the expert panel included the potential insensitivity of the question to a distressed caller, and the increased chance for the non-medically trained call-taker to incorrectly divert an emergency ambulance if they deemed the palliative care patient to be low-acuity.

Future research ought to explore the barriers, facilitators and challenges that the sector, services, communities and individuals would face implementing the components that gained consensus, to inform a strategy to ensure successful translation of the Framework into routine care.^17,33 Researchers should seek endorsement for the arising implementation strategy from professional associations, apply a theory to guide the next steps, and acknowledge the time and resources required to standardise palliative paramedicine practice across Australia; the findings of which could have resonance for palliative care providers and ambulance services worldwide.

Implementing the framework in Australia and other contexts

We envisage this newly developed Framework could play an instrumental role in standardising the practice of palliative paramedicine across different jurisdictions in Australia by specifying targeted interventions of change for individual paramedics and other generalist and specialist palliative care clinicians; state and territory-based ambulance services and broader healthcare services involved in community-based palliative and end-of-life care; and national palliative care policies and practices. Incremental phasing in of the Framework components in differing states and territories could allow for efficacious process evaluation and adaption to compliment the diverse needs of metropolitan, regional, rural and remote communities and healthcare systems. To ensure the Framework is fulfilling its intended purpose, a comprehensive evaluation, including cost-benefit analysis, is recommended. This evaluation ought to examine the efficacy of all individual components of the Framework, in addition to the collective whole, to determine its suitability and ensure its sustainability into the future.

Whilst Australians were the largest participant pool of the expert panel in the Delphi study, international experts were also added to provide a wider perspective and increase the likelihood the Framework could be relevant and applicable to other comparable health systems. Opportunities exist to translate our findings and the resulting Framework into other contexts, including in Franco-German ambulance services, where palliative paramedicine is well under way.^12,16,34 In addition, the Framework could be adapted for low and middle-income countries, including South Africa and Brazil, where significant gaps in paramedic practice have been established and collaborations already fostered.^35,36 Investigating the applicability of our Framework in alternate settings, through qualitative interviews and quantitative surveys with key stakeholders, could assist in the first stages of translating our Framework into future international context-specific policy and best practice.

Strengths and limitations

A consensus method and the use of a Delphi technique were well-suited to developing a framework in this complex, emerging area of palliative care. This study employed a rigorous approach, engaging a large panel of international and multidisciplinary experts. However, we acknowledge that what is ‘important’ in palliative care should be determined, in part, by patients and their families, and this will vary, depending on culture, experience and values. There is evidence of diverse expert panel membership with thirteen countries of origin and Australian First Nations members included in this study, but most panel members are highly educated, of European heritage and living and working in Australia.

Another limitation of this study was the research team selecting experts for the process, potentially leading to preferential selection of participants favourable to our intended research goals and perspectives. However, we aimed to counteract this limitation by clearly defining the target population and sampling approach beforehand and inviting participants to share the invitation within their networks to enhance diversity of the expert panel. This Delphi study did not include the opinions of government policy makers on the expert panel, which could have been a missed opportunity. However, these key decision makers will be important stakeholders to engage in the next phase of the research, when developing an implementation strategy for the Framework.

Conclusion

Despite their traditional emergency response function, paramedic scope of practice is evolving, and they can offer valuable adjunct generalist capability to specialist services in community-based palliative and end-of-life care provision. This study has developed a national Framework with 32 components addressing the macro-, meso- and micro-level interventions required to standardise palliative paramedicine across Australia. The findings may be highly relevant for translation into other countries with similar health systems and services. Future research ought to engage a multidisciplinary team to create an implementation strategy, addressing any perceived barriers, facilitators and challenges for applying the Framework into policy and practice.

Appendix 1: Delphi Round 1 Questionnaire

• (1) Macro-level (systems) components focus on the highest levels of the aggregate health care system for organising specific responses to palliative paramedicine at a structural level.

• 1. Include paramedicine in national and jurisdictional palliative and end-of-life care policies and frameworks.

• - Strongly agree

• - Agree

• - Neither agree nor disagree

• - Disagree

• - Strongly disagree

• 2. Include paramedicine in interdisciplinary palliative and end-of-life care policies and frameworks.

• - Strongly agree

• - Agree

• - Neither agree nor disagree

• - Disagree

• - Strongly disagree

• 3. Provide paramedic services access to electronic medical records, enabling paramedics to access patients' advance care planning and palliative care details in real time.

• - Strongly agree

• - Agree

• - Neither agree nor disagree

• - Disagree

• - Strongly disagree

• 4. Develop and implement State/Territory specific documentation for patients, families and/or carers to complete alongside their healthcare team/s to allow paramedics to rapidly identify a patient's palliative and end-of-life goals of care. Ensure processes for the documentation to be uploaded and accessible electronically.

• - Strongly agree

• - Agree

• - Neither agree nor disagree

• - Disagree

• - Strongly disagree

• 5. Broaden paramedic scope of practice to verify death on scene where appropriate.

• - Strongly agree

• - Agree

• - Neither agree nor disagree

• - Disagree

• - Strongly disagree

• 6. Embed palliative care into all paramedicine undergraduate and postgraduate curriculum, including theoretical and practical components.

• - Strongly agree

• - Agree

• - Neither agree nor disagree

• - Disagree

• - Strongly disagree

• 7. Acknowledge and broaden the paramedicine profession to include clinical roles beyond an ambulance setting that is, paramedics with enhanced palliative care capabilities in primary care settings. For further context, please view these Welsh examples:

• • https://www.ambulance.wales.nhs.uk/Default.aspx?gcid=1873&lan=en

• • https://www.ambulance.wales.nhs.uk/Default.aspx?gcid=1836&lan=en

• - Strongly agree

• - Agree

• - Neither agree nor disagree

• - Disagree

• - Strongly disagree

Other: Please add any further macro-level components you believe should be included in the framework (Qualitative response).

• (2) Meso-level (services) components focus on the intermediate organisational aspects of regulating palliative paramedicine within clinical services and communities.

• 8. Promote healthcare services to recognise the paramedic scope of practice includes palliative and end-of-life care skills.

• - Strongly agree

• - Agree

• - Neither agree nor disagree

• - Disagree

• - Strongly disagree

• 9. Require all ambulance services to maintain a best practice palliative and end-of-life care guideline, including verification of death processes.

• - Strongly agree

• - Agree

• - Neither agree nor disagree

• - Disagree

• - Strongly disagree

• 10. Include a routine question within an ambulance call taker’s algorithm that prompts further questioning about a patient’s palliative care status and notify paramedics before they arrive on scene.

• - Strongly agree

• - Agree

• - Neither agree nor disagree

• - Disagree

• - Strongly disagree

• 11. Standardise paramedic palliative and end-of-life care education and training, including building capacity for paramedics to verify death.

• - Strongly agree

• - Agree

• - Neither agree nor disagree

• - Disagree

• - Strongly disagree

• 12. Provide specialist training pathways to paramedics expressing interest and capacity in palliative and end-of-life care.

• - Strongly agree

• - Agree

• - Neither agree nor disagree

• - Disagree

• - Strongly disagree

• 13. Incorporate and connect paramedics to localised palliative care referral pathways, including alternative referral destinations beyond an Emergency Department.

• - Strongly agree

• - Agree

• - Neither agree nor disagree

• - Disagree

• - Strongly disagree

• 14. Establish interprofessional understanding between ambulance services and palliative care, aged care and general practice services through localised networks.

• - Strongly agree

• - Agree

• - Neither agree nor disagree

• - Disagree

• - Strongly disagree

• 15. Develop public health palliative care campaigns to educate health professionals and the public on a paramedic’s role in delivering community-based palliative and end-of-life care.

• - Strongly agree

• - Agree

• - Neither agree nor disagree

• - Disagree

• - Strongly disagree

Other: Please add any further meso-level components you believe should be included in the framework (Qualitative response).

• (3) Micro-level (individuals) components focus on individual clinicians, patients, families and carers’ experiences that take place inside and around clinical encounters.

• 16. Mandate generalist palliative care capabilities for all paramedics.

• - Strongly agree

• - Agree

• - Neither agree nor disagree

• - Disagree

• - Strongly disagree

• 17. Create optional specialist palliative care capabilities for interested and willing paramedics to pursue.

• - Strongly agree

• - Agree

• - Neither agree nor disagree

• - Disagree

• - Strongly disagree

• 18. Identify and support interested and willing paramedics to become palliative care champions within their respective workplace. Connect these clinicians with local grass roots palliative care initiatives.

• - Strongly agree

• - Agree

• - Neither agree nor disagree

• - Disagree

• - Strongly disagree

• 19. Equip paramedics with communication skills to engage patients, families and carers to partner in palliative and end-of-life care through shared decision-making and debriefing.

• - Strongly agree

• - Agree

• - Neither agree nor disagree

• - Disagree

• - Strongly disagree

• 20. Equip paramedics with resources to refer patients, families and/or carers palliative care supportive services.

• - Strongly agree

• - Agree

• - Neither agree nor disagree

• - Disagree

• - Strongly disagree

• 21. Instil family-centred and culturally appropriate care after death principles into paramedic palliative and end-of-life care practice.

• - Strongly agree

• - Agree

• - Neither agree nor disagree

• - Disagree

• - Strongly disagree

• 22. Provide paramedics access to self-care and peer support services, including debriefing opportunities for unexpected and expected deaths.

• - Strongly agree

• - Agree

• - Neither agree nor disagree

• - Disagree

• - Strongly disagree

• 23. Equip patients, families and carers with appropriate state/territory advance care planning documentation to share with paramedics upon arrival, to allow for the rapid identification of the patient’s palliative and end-of-life goals of care.

• - Strongly agree

• - Agree

• - Neither agree nor disagree

• - Disagree

• - Strongly disagree

• 24. Educate families and carers to provide paramedics with contact details of patient’s healthcare providers, including GP and specialist palliative care services.

• - Strongly agree

• - Agree

• - Neither agree nor disagree

• - Disagree

• - Strongly disagree

Other: Please add any further micro-level components you believe should be included in the framework (Qualitative response).