Patients who are at the end of their lives can be recognized by one or more of the following features:

• The patient is diagnosed with a life-limiting illness
• Care is currently focused on comfort and symptom management, rather than curative interventions
• The patient has a current document outlining their goals for care
• The patient is under the care of a physician or a home care team providing palliative care services

When death is imminent, the individual may be provided with supportive care and comfort measures, with the goal of avoiding medical interventions where appropriate. 

• Establish goals of care in consultation and conversation with the patient, family, and care team.
• It is important to recognize that dying may take hours or days and to diagnose dying is a complex process.
• Imminent death can sometimes be recognized by any, none, or all of the following:
  • Patient uncommunicative, unresponsive, and difficult to arouse
  • Cold, purple, blotchy feet and hands
  • Drowsiness or impaired cognition
  • Decreased urine output
  • Restlessness
  • Congestion and gurgling in the chest
  • Alterations in breathing patterns

• When death is imminent, the patient may be provided with supportive care such as positioning, suctioning, or fans as necessary.  Avoid medical interventions when appropriate.
• Integrity in palliative care practice refers to the importance of respecting the patient’s values, needs, and wishes in the context of a life-limiting condition.
• Recognize and respect that people may have a spiritual and/or religious belief for end-of-life care and that such beliefs may be different from that of paramedics and EMRs/FRs.
• For patients nearing the end of their lives, transfer to the ED can be inappropriate.
• When a clear 'Do Not Resuscitate' (DNR) or 'Medical Orders for Scope of Treatment' (MOST) instruction is in place, paramedics and EMRs/FRs should not start resuscitation when the patient progresses to respiratory or cardiac arrest.  CliniCall consultation required for guidance if clear documentation is not available (e.g., a verbal do-not-resuscitate order).
• Follow the BCEHS procedure for pronouncing death of the patient.
• Witnessing the end of life often elicits a variety of responses from those present.  Cultural beliefs, age, and the nature of the incident may influence the response.
• Once the decision to withhold or discontinue resuscitation has been made, be prepared to console the family, friends, or bystanders at the moment of death.
• Allow the family space to grieve and, when appropriate, attempt to cover the body and close the patient’s eyes.

All palliative and end-of-life patients can be considered for inclusion in the Palliative Care Clinical Pathway (treat and refer) approach to care.  Paramedics must complete required training prior to applying this pathway. EMRs are required to contact CliniCall for consultation to proceed with the ASTaR clinical pathway. 

1. Nova Scotia Health Authority. Nova Scotia Palliative Care Competency Framework. 2017. [Link] 
2. Pallium Canada. Learning Essentials Approach to Palliative Care. 2019. [Link] 
3. Harman SM, et al. Palliative care: The last hours and days of life. In UpToDate. 2020. [Link]

• 2022-01-06: EMRs now authorized to access ASTaR clinical pathway.