Dealing with dying – progressing paramedics' role in grief support

This is an Accepted Manuscript of an article published by Taylor & Francis in Progress in Palliative Care on 18 Jan 2021, available online at: https://www.tandfonline.com/doi/abs/10.1080/09699260.2020.1856634. The author accepted version is made available here under publisher policy. It is deposited under the terms of the Creative Commons Attribution-NonCommercialNoDerivatives License (http://creativecommons.org/licenses/by-nc-nd/4.0/), which permits non-commercial re-use, distribution, and reproduction in any medium, provided the original work is properly cited, and is not altered, transformed, or built upon in any way. Manuscript version 18/02/2021. 1 Title: Dealing with dying - progressing paramedics’ role in grief support Authors: Cheryl Cameron*, Tyne M. Lunn*, Chelsea Lanos, Alan M. Batt * Joint first authors Corresponding author: Cheryl Cameron, MEd, BA(Hons), ACP: Emergency Health Services, Alberta Health, Alberta, Canada; McNally Project for Paramedicine Research, Ontario, Canada. [email protected] ORCiD: 0000-0002-4085-7995. Tyne M. Lunn, ACP: Mobile Integrated Healthcare, Alberta Health Services Emergency Medical Services, Alberta, Canada; McNally Project for Paramedicine Research, Ontario, Canada. ORCiD: 0000-0002-4257-9968 Chelsea Lanos BSc MSc(c) ACP: County of Renfrew Paramedic Service, Ontario, Canada; McNally Project for Paramedicine Research, Ontario, Canada. ORciD: 0000-0003-4909-1305 Alan M. Batt PhD(c) MSc PGCME FHEA CCP: Paramedic Programs, Fanshawe College, Ontario, Canada; Paramedic Science, CQUniversity, QLD, Australia; Paramedicine, Charles Sturt University, NSW, Australia; Department of Paramedicine, Monash University, VIC, Australia; McNally Project for Paramedicine Research, Ontario, Canada. ORCiD: 0000-00016473-5397 Abstract: Paramedics are frequently present at the death of patients and are in a position to provide grief support to family members who are suddenly bereaved, but existing education and system resources have failed to provide paramedics with the necessary tools to do so. Although the literature emphasizes the importance of providing grief training from initial education, through clinical placements and into continuing professional development opportunities, the current state across all health professions is a patchwork of elective, brief, and siloed opportunities. With new interprofessional partnerships developing between paramedicine and palliative care, there is a unique opportunity to better prepare paramedics to adequately participate in the death and dying process and address developing competency in grief support in a more strategic and integrated manner. We suggest employing a multi-faceted approach, focused on recruitment, initial and continuing education, and continued support in clinical practice. Importantly, paramedics will require support from interprofessional colleagues in palliative, grief and bereavement care to provide expertise in educational programs, clinical placements, and support at the patient’s bedside. Now is the time to address grief support across the full continuum of paramedic practice to ensure paramedics are competent to support recently bereaved families. This is an Accepted Manuscript of an article published by Taylor & Francis in Progress in Palliative Care on 18 Jan 2021, available online at: https://www.tandfonline.com/doi/abs/10.1080/09699260.2020.1856634. The author accepted version is made available here under publisher policy. It is deposited under the terms of the Creative Commons Attribution-NonCommercialNoDerivatives License (http://creativecommons.org/licenses/by-nc-nd/4.0/), which permits non-commercial re-use, distribution, and reproduction in any medium, provided the original work is properly cited, and is not altered, transformed, or built upon in any way. Manuscript version 18/02/2021. 2 Keywords: Paramedic; Grief; Bereavement; Palliative Care; End-of-life Care; Non-technical skills Author Declarations The authors declare that this work has not been published elsewhere. The authors declare that they are responsible and accountable for the accuracy and integrity of all aspects of this work. Author Contributions CC, TL, CL and AB designed and conducted the literature searches. CC and TL authored the first draft of the manuscript. All authors contributed to the authoring and editing of the manuscript. All authors have approved the final version for publication. Conflicts of interest The authors declare no conflicts of interest Biographical statements: Cheryl Cameron is an Advanced Care Paramedic currently working in a strategic policy and leadership role with Emergency Health Services, Alberta Health, Alberta, Canada. She is a Fellow with the McNally Project for Paramedicine Research, Ontario, Canada; facilitator of interprofessional team development with the Health Education and Research Commons at the University of Alberta, Alberta, Canada; and, provides both educational and operational program expertise on a number of national initiatives related to paramedicine and palliative care. Tyne M. Lunn is an Advanced Care Paramedic currently working as a Community Paramedic Specialist for the Mobile Integrated Healthcare department of Alberta Health Services Emergency Medical Services, Alberta, Canada; Member with the McNally Project for Paramedicine Research, Ontario, Canada; and, advocate for rural interdisciplinary care and provides practice setting expertise on national grief education for paramedics. Chelsea Lanos is an Advanced Care Paramedic with the County of Renfrew Paramedic Service in Ontario, Canada and is undertaking a Masters of Science in Critical Care at Cardiff University, Cardiff, Wales. She is a Research Assistant with the Ottawa Hospital Research Institute Department of Emergency Medicine, and a Fellow with the McNally Project for Paramedicine Research, Ontario, Canada. Alan M. Batt is Adjunct Associate Professor of Paramedic Science at CQUniversity, Queensland, Australia; Sessional Lecturer in Paramedicine at Charles Sturt University, NSW, Australia; Professor and Research Lead in the Paramedic Programs at Fanshawe College, Ontario, Canada; and, Senior Fellow with the McNally Project for Paramedicine Research, Ontario, Canada. He is a PhD candidate in the Department of Paramedicine at Monash University, VIC, Australia. This is an Accepted Manuscript of an article published by Taylor & Francis in Progress in Palliative Care on 18 Jan 2021, available online at: https://www.tandfonline.com/doi/abs/10.1080/09699260.2020.1856634. The author accepted version is made available here under publisher policy. It is deposited under the terms of the Creative Commons Attribution-NonCommercialNoDerivatives License (http://creativecommons.org/licenses/by-nc-nd/4.0/), which permits non-commercial re-use, distribution, and reproduction in any medium, provided the original work is properly cited, and is not altered, transformed, or built upon in any way. Manuscript version 18/02/2021. 3 Introduction Clinical work is immersed with grief, which contributes to the challenges of the ever evolving practice of paramedicine. Grief is non-linear, unpredictable, and varies across diverse intersections of society. Grief support work is woven with nuance and context, is unique to those involved, and as such, a one-size-fits-all approach is remiss if we are to provide adequate support to those who are grieving. Although dealing with death is an anticipated part of the job for many health professionals across varied practice settings, it is generally afforded little attention in curricula and continuing competency activities. Multiple health professions report a lack of clinician comfort with dying and supporting families who are grieving [1–4]. As part of their professional role, paramedics are frequently present at the death of patients and thus are well positioned to provide grief support to family members and others who are suddenly bereaved. Despite this, existing education and system resources have largely failed to provide paramedics with the necessary tools [4,5]. As the role of paramedics within the health system continues to expand to enhance care in the community (e.g. community paramedicine, treat and refer for patients receiving palliative care), paramedics will find themselves in such situations more often, and potentially for extended periods of time as the focus of care shifts from transport to provision of appropriate care [6–15]. There now exists an opportunity to better prepare paramedics to participate in the death and dying process, which we posit requires a multifaceted and multidisciplinary approach focused on recruitment, initial and continuing education, and continued support in clinical practice. Recruitment Traditionally, paramedicine education has focused on clinical knowledge and procedural skills but is evolving to recognize the need for strategies that enhance psychosocial attributes required for paramedic work [16]. The work of paramedicine requires excellence in attributes such as communication, critical decision-making, empathy, compassion, teamwork, resilience, and leadership [16,17]. Ensuring patient autonomy and meeting goals of care often relies on enhanced skill in the psychosocial aspects of paramedicine. However, not all paramedics are innately versed in non-technical skills (NTS) and the issue is afforded little attention in the literature. Although NTS are identified as core elements of paramedic practice, the discussion to date has largely focused on how to determine which skills are most important [18]. From a recruitment perspective, we may need to consider whose character best fits the dynamic nature of paramedic work. With the aim of recruiting best character fit into paramedic education, it is important to contextualize professionalism as it pertains to paramedicine; it can be understood as clinical excellence underpinned by principles, values and behaviours of conduct and competency that support trust of the public [19]. We will discuss the traits and domains of the paramedic professional, to be differentiated from the professionalisation of paramedicine, whereby paramedics are pursuing self-governance and expanded education and roles. Contrasted to medicine, paramedicine remains a young profession, with ongoing efforts to define This is an Accepted Manuscript of an article published by Taylor & Francis in Progress in Palliative Care on 18 Jan 2021, available online at: https://www.tandfonline.com/doi/abs/10.1080/09699260.2020.1856634. The author accepted version is made available here under publisher policy. It is deposited under the terms of the Creative Commons Attribution-NonCommercialNoDerivatives License (http://creativecommons.org/licenses/by-nc-nd/4.0/), which permits non-commercial re-use, distribution, and reproduction in any medium, provided the original work is properly cited, and is not altered, transformed, or built upon in any way. Manuscript version 18/02/2021. 4 professionalism with more specificity. Some countries such as the UK have made progress in defining the paramedic professional. Acknowledging that definitions of professionalism across medicine, paramedicine, and allied healthcare fields vary, there are overlapping domains that when possessed by healthcare professionals, benefit delivery of care. In medical education, researchers have identified that professionalism is paramount for success in medical practice [20]. Others have discussed the need to move the understanding of professionalism in medical education away from an innate personality trait, and instead to skills that can be taught and cultivated [21]. Here the term ‘professionalism’ encompasses both clinical competence and psychosocial domains. NTS encompassed within professionalism across healthcare professions (such as communication, empathy, compassion, integrity, trust, respect, and advocacy among others), might be most relevant for grief work. If we assume that paramedics who inherently possess professionalism are best suited for grief support care, this can help to inform paramedic educators and recruiters when selecting individuals who are best fit for grief work from the outset. When seeking persons who exhibit professionalism, the difficulty lies when we attempt to observe and measure NTS. To solve this in paramedicine recruitment, we can be guided by our physician colleagues who have increasingly prioritized professionalism in medical curricula and accreditation [20,21]. Medical education literature reveals an increased use of Situational Judgement Testing (SJT) for medical students as an effective tool to assess for non-academic factors relating to professionalism [20]. Further study into selection for medical education illustrates that SJT has incremental validity over knowledge testing [22], which may inform strategies to solidify outcomes between paramedic candidate selection and job performance. When caring for our diverse patient population, it is valuable for those grieving to receive empathic support from practitioners they might identify with or who may have relevant or shared experiences. As a method for improving diversity among healthcare professionals, the use of SJT in candidate selection has proved beneficial in reducing subjectivity and broadening access to medical education [23]. When properly constructed and delivered, SJT has proven to be fair with the added value of being customizable and calibrated for specific NTS [24]. Implementing SJT for recruitment and selection into education programmes is not without challenges or costs; however, from a systems perspective, there are downstream benefits and potential cost savings. The question then becomes, where is the most effective place to invest time and money? Integrating SJT presents a possible means by which to improve recruitment, and can result in higher job performance and potential for employee retention [25]. As a result, systems may realise cost savings otherwise lost to workforce turnover and continual hiring and onboarding of new employees [25]. Approaches to SJT vary based on intent of use. SJT content can be developed to be context-dependent (specific) or context-independent (general) [26]. Initial development costs may be reduced by utilizing context-independent/general content in SJT for recruitment, then adapting SJT with specific/context-dependent knowledge in training [26]. For example, SJT used in recruitment or selection to education programmes can target general professional attributes, then professionalism can be further cultivated and enhanced during education using contextualized SJT as a teaching method. The cost for resource-intense SJT development, such as subject matter experts, can be invested in trainees who are already a good fit, rather than in the recruitment phase [26]. This is an Accepted Manuscript of an article published by Taylor & Francis in Progress in Palliative Care on 18 Jan 2021, available online at: https://www.tandfonline.com/doi/abs/10.1080/09699260.2020.1856634. The author accepted version is made available here under publisher policy. It is deposited under the terms of the Creative Commons Attribution-NonCommercialNoDerivatives License (http://creativecommons.org/licenses/by-nc-nd/4.0/), which permits non-commercial re-use, distribution, and reproduction in any medium, provided the original work is properly cited, and is not altered, transformed, or built upon in any way. Manuscript version 18/02/2021. 5 Additionally, in the current era of rapidly evolving technologies, video-based SJT may offer greater selection validity (compared to written tests) or lower costs than current selection methods (high-fidelity simulations, multiple mini interviews or behavioural observation) [27]. While the use of SJT in paramedicine is not yet widespread and more research is needed [18,28], it presents a possible means by which to improve diverse recruitment and selection into education programmes, job performance, wellbeing, and influence professional education. Others have discussed the need to move the understanding of professionalism in medical education away from an innate personality trait, and instead to skills that can be taught and cultivated [21]. Aligned with recommendations from a longitudinal assessment of professionalism in medical education, educational and organizational leaders may desire to follow medicine’s lead to incorporate SJT early into recruitment and curricula [20]. With adjusted efforts from the outset focused on diversity and best fit candidates for practitioner wellness, curricula can then be adjusted to expand the focus to include NTS relating to grief. The focus on professionalism should then be applied to entry to practice and continuing education ensuring these attributes are continually evaluated and improved upon within paramedicine so that practitioners may enhance their ability to provide grief care. Education As it stands, few paramedic programs at the introductory or advanced care level provide any education related to grief or bereavement [4,6,29,30]. Little attention is given to death or supporting recently bereaved families in core resources used in paramedic education (e.g. a handful of bullet points in some core texts). Education related to death and dying is generally limited to providing physical comfort and transport to a facility, or how to deliver a death notification [29,31,32]. Death notification training is often focused around legal technicalities and procedures, modeled after education designed for police officers, and does not focus on grief, bereavement, or tailoring for a patient-centered or culturally appropriate approach [4]. Although many continuing education courses focused on resuscitation now include content related to dealing with death, these courses are not provided to all paramedics and such content remains brief and omits many complexities of grief care. In addition, this content is often taught by paramedic educators, rather than by experts in grief or bereavement [33]. Traditional paramedic education has little focus on practitioner attitudes and values [34], let alone a focus on perceptions and fears about grief and the psychosocial impacts of death and dying [4]. Although there is a paucity of literature regarding grief and bereavement education in paramedicine, literature from other health professions can further inform our understanding. Across health professions, the educational objectives of grief training tend to include increasing knowledge, building capacity for self-awareness and reflection, improving communication skills, and working within interprofessional teams. Despite the importance of providing grief training longitudinally across initial education, clinical placements, and continuing professional development, the current state across the health professions is a patchwork of elective, brief, and siloed opportunities [1]. Training is mostly provided as a singular intervention (e.g. a lecture, This is an Accepted Manuscript of an article published by Taylor & Francis in Progress in Palliative Care on 18 Jan 2021, available online at: https://www.tandfonline.com/doi/abs/10.1080/09699260.2020.1856634. The author accepted version is made available here under publisher policy. It is deposited under the terms of the Creative Commons Attribution-NonCommercialNoDerivatives License (http://creativecommons.org/licenses/by-nc-nd/4.0/), which permits non-commercial re-use, distribution, and reproduction in any medium, provided the original work is properly cited, and is not altered, transformed, or built upon in any way. Manuscript version 18/02/2021. 6 lecture series, or short workshop), outside the core curriculum of the profession, and aligned with elective or continuing competency opportunities. Most grief training programs are voluntary in nature, which contributes to a lack of assurance that health professionals possess a standard skill set in grief care. In addition, little evidence speaks to the effectiveness of these programs, with evaluation largely reliant on self-assessment to identify changes in knowledge and attitudes related to grief [1]. We could not identify any literature that evaluated sustained change in the participants' experience in supporting family or colleagues through grief in clinical situations or the resulting experience of families. Similar to many other health professions, paramedic education programs continue to focus on clinical knowledge (e.g. physiology, pathophysiology, pharmacology) and the development of tactile psychomotor skills (e.g. starting an IV, airway management). Despite the fact that everyday paramedic work involves handling difficult and stressful situations, employing effective communication strategies, and adapting to dynamic environments, considerably less time is spent developing NTS. Increasing practitioner comfort and capacity for providing grief support will require capacity building among educators to develop expertise in teaching and evaluating appropriate NTS. Building capacity in NTS will require different educational methodologies and alternative approaches to traditional lectures and skill stations. Educators will require expertise and comfort with other approaches (e.g. role play, simulation, interactions with standardized patients) and skillful debriefing to engage learners in critical thinking and reflection on their own values and beliefs related to death and dying [35]. Understanding that grief work has a profound impact on both those performing and receiving care, another essential area of concern is practitioner well-being. Leading with an emphasis on student well-being may be the best place to initially focus when teaching professionalism [21]. Partnerships with grief experts and other health professionals will also be critical to bring content expertise to a multidisciplinary instructional team. Even with a focus on developing NTS in the classroom, learners require opportunities to apply NTS in practice. In many health professions, clinical placements and practicums are a core component of entry level to practice education where students build and demonstrate competence in various clinical settings. In general, paramedic clinical programs focus on immersion in specific settings such as anaesthesia, obstetrics, emergency medicine, critical care and pediatrics to facilitate exposure to certain clinical situations (e.g. advanced airway management, imminent delivery, management of pediatric patients) [36]. Students also participate in operational ambulance practicums where patient presentations are unpredictable, potentially leaving students with insufficient or variable practice experiences with situations involving grief. Although there may be opportunities in these clinical placements to focus on skills related to grief, the learning objectives for such placements tend to remain focused on didactic knowledge and clinical skills. Other health professions have seen value in dedicated experiential placements in palliative care settings (e.g. hospice, palliative care in-patient units) or shadowing practitioners (e.g. chaplains, palliative care physicians, social workers) who provide grief support as a large component of their clinical practice setting [37]. Placements or shadowing practitioners specifically in community settings may also help to build interprofessional relationships between paramedics and the palliative care community teams they work with to provide palliative and grief support in the home This is an Accepted Manuscript of an article published by Taylor & Francis in Progress in Palliative Care on 18 Jan 2021, available online at: https://www.tandfonline.com/doi/abs/10.1080/09699260.2020.1856634. The author accepted version is made available here under publisher policy. It is deposited under the terms of the Creative Commons Attribution-NonCommercialNoDerivatives License (http://creativecommons.org/licenses/by-nc-nd/4.0/), which permits non-commercial re-use, distribution, and reproduction in any medium, provided the original work is properly cited, and is not altered, transformed, or built upon in any way. Manuscript version 18/02/2021. 7 setting. These placements could specifically focus on NTS such as communication, interprofessional collaboration, shared decision making, and patient centered care; the foundations of providing appropriate grief support. Preceptors whose practice centers around having difficult conversations with patients and families may also be in a stronger position to provide appropriate preceptorship to paramedics. Enhanced opportunities to hone and practice NTS will have positive impacts for learners, as competency in NTS is transferable across practice settings and underpins excellence in paramedic practice. Support in clinical practice Let’s assume for a moment that we address the highlighted issues, recruit the right people, and educate them appropriately. How do we then ensure paramedics are best positioned to support patients and families in their grief? In turn, how can the system better support paramedics to allow them to provide adequate grief support to patients and families? The gaps highlighted in recruitment and education are mirrored in paramedic resources. Paramedics are often accessed as a resource within the healthcare system (particularly outside of regular working hours) where other services and care teams are often unavailable [38]. Grief and bereavement supports are no exception. In many cases, paramedics assume the grief counsellor role in cases of sudden death, for example following a termination of resuscitation or death pronouncement, and in anticipated death situations such as palliative care or medical assistance in dying cases. The skills necessary to perform this role are typically informally cultivated with clinical experience and case exposure, and therefore can pose a challenge for newly qualified paramedics or less experienced healthcare providers [3]. At this point, it is important to differentiate the paramedic role in sudden, unexpected death and dying, versus the paramedic role in the palliative care or anticipated death setting, as these demand different clinical and emotional skill sets, especially as they relate to the grieving family. The key to supporting paramedic involvement in sudden, unexpected death is likely rooted in educational and training opportunities [39]. Though the integration of grief training in paramedic education seems imperative, opportunities for continuing education are equally important. Providing paramedics with continued professional development opportunities related to grief and bereavement may improve their knowledge and skills, and in turn may aid with the development of appropriate attitudinal competencies. Prior clinical experience may also facilitate better reflection on existing gaps that contribute to the challenges faced by paramedics when providing grief and bereavement support to families. By contrast, supporting paramedics in their role in the anticipated or expected death setting may lie in better systemic integration of paramedics within multidisciplinary care teams. This would afford paramedics access to broader grief and bereavement resources, and thus provide paramedics with the opportunity to better support patients and families along the death and dying spectrum. Ideally, this would enable the early identification of families in need of grief support, which may in turn decrease the acuity of mobilizing resources at the time of death. Ongoing support may also help to alleviate caregiver and family burnout in palliative care, and end of life care. In turn, this This is an Accepted Manuscript of an article published by Taylor & Francis in Progress in Palliative Care on 18 Jan 2021, available online at: https://www.tandfonline.com/doi/abs/10.1080/09699260.2020.1856634. The author accepted version is made available here under publisher policy. It is deposited under the terms of the Creative Commons Attribution-NonCommercialNoDerivatives License (http://creativecommons.org/licenses/by-nc-nd/4.0/), which permits non-commercial re-use, distribution, and reproduction in any medium, provided the original work is properly cited, and is not altered, transformed, or built upon in any way. Manuscript version 18/02/2021. 8 may result in a decrease in crises prompting emergency paramedic engagement, and allow for better family support at the time of death through improved access to alternative care resources. As an additional consideration, in most paramedic systems some form of medical or clinical oversight is readily available when consultation is necessary, or would be of benefit to patient care. However, paramedics lack such a resource in the context of grief and bereavement, which may further contribute to inadequate support for grieving families and individuals. Access to grief consultant teams should be considered as a viable part of a greater system wide solution. Specialty grief consultant teams may also positively benefit practitioner health and professional development by creating a system intersection that may improve opportunities for practitioner peer support and allow for feedback, evaluation, and ongoing education directly related to practice. Despite the current lack of system infrastructure to support paramedics’ role in providing grief support [4], there is a growing focus on expanding paramedic’s role in supporting palliative care across Canada [40], and work has begun to develop grief education specific for paramedics [41]. With increased collaboration between paramedicine and the palliative care community, now is the time to take advantage of these new relationships to address grief support across the full continuum of paramedic practice from recruitment, through initial and continuing education, and continued support in clinical practice to ensure paramedics are competent to support recently bereaved families. Considerations To inform this paper we performed multiple literature searches of both published and grey literature related to grief and professional practice. Furthermore, this article was informed by our individual experiences with palliative care, death and dying, and the recruitment and education of paramedics. However, it should be noted that this article does not claim to provide a systematic overview of the grief literature, and instead is intended to serve as a commentary piece to promote further discussion of the role of paramedics in grief support. Conclusion The nature of paramedic work means regular interaction with those who are bereaved and grieving. However to date, little attention has been paid to how paramedics can support those who are grieving. The opportunity exists now to move forward in a trajectory that reinforces existing practice with grief strategies to benefit patients, families and practitioners. Selective recruitment may lay the foundation for successfully cultivating NTS in new paramedics by integrating intentional and appropriate teaching methodologies into the core curricula. Educational institutions should consider the inclusion of clinical placements in practice settings where expertise in grief and bereavement is prevalent, and students can hone foundational NTS that support competency in grief support. Paramedics should develop collegial relationships and seek ongoing professional development opportunities with health care professionals experienced in grief care. Paramedic This is an Accepted Manuscript of an article published by Taylor & Francis in Progress in Palliative Care on 18 Jan 2021, available online at: https://www.tandfonline.com/doi/abs/10.1080/09699260.2020.1856634. The author accepted version is made available here under publisher policy. It is deposited under the terms of the Creative Commons Attribution-NonCommercialNoDerivatives License (http://creativecommons.org/licenses/by-nc-nd/4.0/), which permits non-commercial re-use, distribution, and reproduction in any medium, provided the original work is properly cited, and is not altered, transformed, or built upon in any way. Manuscript version 18/02/2021. 9 services should investigate opportunities to develop partnerships with in-system peer clinical grief consultant teams to support paramedics in the field. In order to be fully integrated along the death and dying continuum of care, paramedics will require support from interprofessional colleagues in palliative, grief and bereavement care who can provide expertise within educational programs, support clinical placements, and facilitate consultations at the patient’s bedside. 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