Palliative and End-of-Life Care in Prehospital Medicine: From First Principles to Final Hours

This three-part series from the Pre-Hospital Care Podcast explores the evolving and critical role of ambulance clinicians in palliative and end-of-life care, from first principles through to the final hours of life.In Part 1, we introduce key concepts of palliative and end-of-life care alongside a dedicated specialist team. We examine the differences between generalist and specialist palliative care, the challenges of identifying patients in their last year of life, and the service gaps and educational barriers within prehospital settings. Tools like SPICT, referral pathways, advanced care planning, and the importance of simulation training and national collaboration are all discussed.Part 2 takes a closer look at the final year of life in the prehospital setting. We explore the rapid, high-stakes decisions ambulance clinicians must make, often without a full medical history, and how documentation, such as advance directives, can guide care. We also examine shared decision-making, the NHS Long Term Plan, and the cultural, systemic, and logistical barriers that complicate effective advance care planning.Part 3 focuses on the final days and hours. Paramedics are often the first to recognise active dying, navigating symptoms like terminal agitation, carer breakdown, and family distress. We discuss anticipatory medications, breaking bad news using frameworks such as Ask-Tell-Ask, and the vital emotional support clinicians provide. The series closes by reflecting on cultural diversity, from language barriers to religious rituals, reminding us that compassionate, person-centred care must be inclusive and adaptable for every patient and family.If you want to catch up on the Palliative Care Series on the PHCP, you can listen to the full collection below. Across these three episodes, we explore the evolving role of ambulance clinicians in end-of-life care, the challenges of identifying patients in their last year of life, and the complexities of delivering compassionate, patient-centred care in the pre-hospital environment. This also includes a fourth episode on Palliative Care Case Studies. Listen to all episodes here:Episode 1: https://podcasts.apple.com/gb/podcast/palliative-and-end-of-life-care-in-pre-hospital/id1441215901?i=1000710805396Episode 2: https://podcasts.apple.com/gb/podcast/the-last-year-of-life-palliative-and-end-of/id1441215901?i=1000714113716Episode 3: https://podcasts.apple.com/gb/podcast/the-dying-patient-palliative-and-end-of-life-care-part-3/id1441215901?i=1000718217210Episode 4: https://podcasts.apple.com/gb/podcast/palliative-care-case-studies-with-the-palliative-and/id1441215901?i=1000727796192This episode is sponsored by PAX: The gold standard in emergency response bags.When you’re working under pressure, your kit needs to be dependable, tough, and intuitive. That’s exactly what you get with PAX. Every bag is handcrafted by expert tailors who understand the demands of pre-hospital care. From the high-tech, skin-friendly, and environmentally responsible materials to the cutting-edge welding process that reduces seams and makes cleaning easier, PAX puts performance first. They’ve partnered with 3M to perfect reflective surfaces for better visibility, and the bright grey interior makes finding gear fast and effortless, even in low light. With over 200 designs, PAX bags are made to suit your role, needs, and environment. And thanks to their modular system, many bags work seamlessly together, no matter the setup.PAX doesn’t chase trends. Their designs stay consistent, so once you know one, you know them all. And if your bag ever takes a beating? Their in-house repair team will bring it back to life.PAX – built to perform, made to last.Learn more at https://www.pax-bags.com/

For many clinicians, the traditional pathways of healthcare offer purpose and stability, but they can also feel restrictive, misaligned with evolving identities, or incompatible with a life that values adventure, education, and time outside conventional systems. Changing direction within or adjacent to healthcare is rarely a single leap; more often, it is a series of deliberate steps shaped by curiosity, burnout, growth, and a desire for sustainability.In this conversation, Laura Hall and Kelly Wright bring their lived experiences to bear on that reality. Laura is currently a pre- and post-op nurse in a small Colorado town, a wilderness medicine instructor, and a trail-running coach who has built a career around adaptability, education, and performance in demanding environments. Kelly is a flight nurse and endurance athlete whose professional journey reflects both the physical toll and the profound privilege of high-acuity care. Together, they are the voices behind High Adventure Healthcare, a platform dedicated to honest discussion, education, and redefining what a healthcare career can look like.This episode explores what it really means to change course, without abandoning hard-earned skills or identity. It is a grounded, practical discussion about fear, flexibility, reinvention, and how clinicians can build careers that support both longevity and life beyond the uniform. You can check out the fantastic Substack blog page here: https://highadventurehealthcare.substack.com/This episode is sponsored by PAX: The gold standard in emergency response bags.When you’re working under pressure, your kit needs to be dependable, tough, and intuitive. That’s exactly what you get with PAX. Every bag is handcrafted by expert tailors who understand the demands of pre-hospital care. From the high-tech, skin-friendly, and environmentally responsible materials to the cutting-edge welding process that reduces seams and makes cleaning easier, PAX puts performance first. They’ve partnered with 3M to perfect reflective surfaces for better visibility, and the bright grey interior makes finding gear fast and effortless, even in low light. With over 200 designs, PAX bags are made to suit your role, needs, and environment. And thanks to their modular system, many bags work seamlessly together, no matter the setup.PAX doesn’t chase trends. Their designs stay consistent, so once you know one, you know them all. And if your bag ever takes a beating? Their in-house repair team will bring it back to life.PAX – built to perform, made to last.Learn more at ⁠https://www.pax-bags.com/en/⁠

In this blog audio, we interview Kelly Wright. In the piece, we examine the multifaceted and increasingly precarious role of National Park rangers, portraying them as both frontline first responders and long-term stewards of fragile ecosystems. The narrative positions rangers at the intersection of public safety and environmental protection, highlighting how their responsibilities extend far beyond traditional perceptions of park oversight.Kelly describes how modern rangers are required to manage an exceptionally broad operational remit. Their work encompasses complex search and rescue missions, emergency and prolonged field-based clinical care, wildfire prevention, and the protection of sensitive habitats. Often operating in austere and remote environments, rangers are expected to make high-consequence decisions with limited resources while balancing the needs of visitors and the preservation of wilderness.Against this backdrop, Kelly warns of a growing and dangerous imbalance. As public lands experience record levels of visitation, ranger services are simultaneously facing shrinking staff numbers and sustained funding reductions. This disconnect between rising demand and diminishing capacity increases risk for both visitors and responders, stretching already-thin systems closer to failure.Through specific accounts of backcountry medical evacuations and conservation efforts, the narrative illustrates the critical role rangers play as the final safeguard against human tragedy and environmental degradation. These examples underscore how, in many settings, rangers represent the last line of defence when prevention has failed, and consequences are immediate.Kelly argues that meaningful reinvestment in ranger services is essential, not only to protect those who venture into wild places, but to ensure the continued survival of the landscapes themselves. Without adequate support, the dual mission of public safety and environmental stewardship becomes increasingly unsustainable. Read the blog here: https://highadventurehealthcare.substack.com/p/where-wilderness-medicine-meets-conservationThis Podcast is sponsored by World Extreme Medicine.World Extreme Medicine provides internationally recognised education for clinicians and operators working in pre-hospital, remote, expedition, humanitarian, and high-risk environments. Their programmes focus on practical, experience-led learning, equipping professionals with the skills to make sound clinical and operational decisions when resources are limited, evacuation is delayed, and conditions are extreme.With courses covering expedition and wilderness medicine, hostile environments, dive medicine, human performance, leadership, and austere care, World Extreme Medicine brings together a global faculty with real-world experience from some of the most challenging settings on earth. To explore courses, free educational resources, and upcoming webinars, visit: ⁠www.worldextrememedicine.com

In this episode of the Pre-Hospital Care Podcast, we explore the evolving management of Neck of Femur (NOF) fractures, one of the most common and operationally challenging presentations in pre-hospital care. With an ageing population driving a rising incidence, these injuries represent a significant clinical and systems burden, requiring both rapid assessment and increasingly sophisticated early management.Joined by Emma Moore, Senior Lecturer in Paramedic Science at CQUniversity Australia, the discussion unpacks current challenges and future directions in care. We examine the growing role of pre-hospital care bundles, specialist triage pathways, and how system design is adapting to improve patient outcomes. A key focus is analgesia, including the expanding use of fascia iliaca blocks and multimodal pain strategies in the pre-hospital environment.The episode also highlights the key clinical distinctions between older and younger patients, in which priorities shift from early mobilisation to joint preservation, despite historically poor outcomes in the latter group. Operational considerations such as scene time versus rapid transport, and the skills paramedics need for the next generation of care, are explored in depth.This episode offers practical insight and forward-looking perspectives for clinicians aiming to optimise NOF fracture management in the pre-hospital setting. Read more on Emma's research and work here: https://journals.sagepub.com/doi/10.1177/14604086251350629This Podcast is sponsored by World Extreme Medicine.World Extreme Medicine provides internationally recognised education for clinicians and operators working in pre-hospital, remote, expedition, humanitarian, and high-risk environments. Their programmes focus on practical, experience-led learning, equipping professionals with the skills to make sound clinical and operational decisions when resources are limited, evacuation is delayed, and conditions are extreme.With courses covering expedition and wilderness medicine, hostile environments, dive medicine, human performance, leadership, and austere care, World Extreme Medicine brings together a global faculty with real-world experience from some of the most challenging settings on earth. To explore courses, free educational resources, and upcoming webinars, visit: ⁠www.worldextrememedicine.com

In this piece, Kelly Wright explores how choosing a nursing specialty is less about prestige or opportunity and more about aligning personal characteristics with the realities of the clinical environment. She argues that long-term satisfaction and sustainability in nursing depend on an honest assessment of one’s personality, lifestyle priorities, and stress tolerance, rather than external expectations of what a nurse “should” do.Kelly describes intensive care nursing as a natural fit for clinicians who value precision, structure, and deep engagement with clinical data. ICU practice rewards meticulous attention to detail and comfort with complex technology, as well as the patience required to support patients through prolonged and often uncertain recovery trajectories. For nurses who find meaning in continuity of care and mastering intricate physiological management, the ICU can be a deeply fulfilling environment.By contrast, the Emergency Department is presented as a domain for those who thrive amid unpredictability and rapid decision-making. Kelly highlights how ED nursing demands swift assessment, adaptability, and comfort with constant turnover, making it well-suited to individuals energized by variety and controlled chaos rather than long-term patient relationships.Flight nursing is positioned as a hybrid specialty that draws elements from both ICU and emergency care while adding a distinct layer of autonomy and physical challenge. Kelly notes that this role appeals to nurses who are comfortable operating in austere environments, managing limited resources, and tolerating significant physical and environmental stressors, all while delivering high-acuity care far from traditional clinical support.A key message of the article is the inherent flexibility within the nursing profession. Kelly emphasizes that nurses are not locked into a single path and can move between specialties as their interests, resilience, and life circumstances evolve. This adaptability allows practitioners to seek roles where professional development feels purposeful and engaging, rather than exhausting or obligatory.Ultimately, Kelly concludes that the most successful and enduring nursing careers are built on alignment. Regardless of specialty, nurses who choose environments that complement their emotional resilience, learning style, and long-term goals are more likely to remain engaged, healthy, and fulfilled throughout their careers. Read the blog here: https://highadventurehealthcare.substack.com/p/choosing-your-critical-care-adventureThis Podcast is sponsored by World Extreme Medicine.World Extreme Medicine provides internationally recognised education for clinicians and operators working in pre-hospital, remote, expedition, humanitarian, and high-risk environments. Their programmes focus on practical, experience-led learning, equipping professionals with the skills to make sound clinical and operational decisions when resources are limited, evacuation is delayed, and conditions are extreme.With courses covering expedition and wilderness medicine, hostile environments, dive medicine, human performance, leadership, and austere care, World Extreme Medicine brings together a global faculty with real-world experience from some of the most challenging settings on earth. To explore courses, free educational resources, and upcoming webinars, visit: ⁠www.worldextrememedicine.com

Today on the Pre-Hospital Care Podcast, we are joined by Paige Mason, MA, a researcher, paramedic, and educator whose work reframes how we think about wellbeing on the front line. In this episode, we unpack her work and what it means for individual paramedics, teams, and services striving to build resilient, healthy, and sustainable careers in pre-hospital care.Paige is a Primary Care Paramedic with the Ottawa Paramedic Service and a member of the McNally Project for Paramedicine Research, where she advocates for paramedic-driven inquiry.  She holds an Honours Bachelor of Arts in Kinesiology from Western University and completed her Master of Arts in Interdisciplinary Studies at Royal Roads University, graduating with distinction for her thesis, Paramedic Flourishing at Work: A Way Forward. Her research explores what enables some paramedics to thrive in one of the most demanding health professions, shifting the focus from reducing burnout to understanding and fostering workplace flourishing. Paige’s interests span organisational culture, human factors, decision making, positive psychology, and appreciative inquiry in paramedicine. Paige's research can be found here: https://www.viurrspace.ca/server/api/core/bitstreams/90743451-ac36-4f85-963e-68fec5be594e/contentThis Podcast is sponsored by World Extreme Medicine.World Extreme Medicine provides internationally recognised education for clinicians and operators working in pre-hospital, remote, expedition, humanitarian, and high-risk environments. Their programmes focus on practical, experience-led learning, equipping professionals with the skills to make sound clinical and operational decisions when resources are limited, evacuation is delayed, and conditions are extreme.With courses covering expedition and wilderness medicine, hostile environments, dive medicine, human performance, leadership, and austere care, World Extreme Medicine brings together a global faculty with real-world experience from some of the most challenging settings on earth. To explore courses, free educational resources, and upcoming webinars, visit: ⁠www.worldextrememedicine.com

In The Physical Toll of High Adventure Healthcare, Kelly Wright examines the often-unacknowledged physical and psychological cost of working at the sharp edge of medicine. Drawing on experience from flight nursing and hospital-based practice, she describes how cumulative occupational stressors steadily erode clinician health, threatening both well-being and career longevity.Kelly outlines how healthcare professionals operating in aviation and other high-intensity clinical environments are exposed to a combination of environment-specific stressors, including continuous vibration, excessive noise, hypoxia, and confined workspaces that limit safe posture and movement. These factors do not exist in isolation but compound the routine demands of clinical work, accelerating musculoskeletal fatigue and long-term physical damage.Beyond these environmental challenges, the article highlights the mechanical strain common across much of healthcare practice. Repetitive lifting, manual handling, prolonged shifts, disrupted recovery, and sustained awkward postures are presented as everyday hazards that, over time, contribute to chronic injury, reduced physical capacity, and premature departure from clinical roles.Kelly also addresses the growing problem of workplace violence directed at healthcare professionals and its profound downstream effects. Physical injury, fear at work, emotional exhaustion, and burnout are described as interconnected outcomes that erode morale, professional identity, and the ability to sustain a long-term career. The article makes clear that physical harm and psychological injury are inseparable and must be addressed together.Protecting clinicians requires more than admiration for their resilience or heroism; it demands deliberate, systemic action. If healthcare systems wish to retain experienced, capable professionals, they must actively reduce preventable harm and invest in safer working environments for those who care for others at high personal cost. You can read the blog here: https://highadventurehealthcare.substack.com/p/the-physicality-of-healthcareThis episode is sponsored by PAX: The gold standard in emergency response bags.When you’re working under pressure, your kit needs to be dependable, tough, and intuitive. That’s exactly what you get with PAX. Every bag is handcrafted by expert tailors who understand the demands of pre-hospital care. From the high-tech, skin-friendly, and environmentally responsible materials to the cutting-edge welding process that reduces seams and makes cleaning easier, PAX puts performance first. They’ve partnered with 3M to perfect reflective surfaces for better visibility, and the bright grey interior makes finding gear fast and effortless, even in low light. With over 200 designs, PAX bags are made to suit your role, needs, and environment. And thanks to their modular system, many bags work seamlessly together, no matter the setup.PAX doesn’t chase trends. Their designs stay consistent, so once you know one, you know them all. And if your bag ever takes a beating? Their in-house repair team will bring it back to life.PAX – built to perform, made to last.Learn more at ⁠https://www.pax-bags.com/en/⁠

Out-of-hospital cardiac arrest remains one of the most emotionally complex and ethically challenging events in pre-hospital care. Families can transition from normality to devastating loss within minutes, while clinicians must make rapid, high-stakes decisions that often leave a lasting emotional impact. Traditionally, EMS practice has centred on the moment of “termination of resuscitation”, a clinical decision that often results in abrupt death notifications and limited family involvement. But a growing body of work challenges this model, suggesting that it may unintentionally amplify trauma for both families and providers.In today’s episode, we’re joined by Dr Darren Braude, Paramedic, Director of the Centre for Prehospital Resuscitation and ECMO, Chief of the Division of Prehospital, Austere and Disaster Medicine. Dr Braude is one of the leading voices behind a powerful reframing: viewing the end of resuscitative efforts not as termination, but as the withdrawal of life support.Borrowing principles from ICU end-of-life care, this approach centres families, promotes clearer communication, and acknowledges that CPR and ventilation are themselves forms of life support. Today, we explore how this model can transform the way EMS navigates death, grief, and humanity in the field. You can read the article this interview is based on here: https://pubmed.ncbi.nlm.nih.gov/40928306/This episode is sponsored by PAX: The gold standard in emergency response bags.When you’re working under pressure, your kit needs to be dependable, tough, and intuitive. That’s exactly what you get with PAX. Every bag is handcrafted by expert tailors who understand the demands of pre-hospital care. From the high-tech, skin-friendly, and environmentally responsible materials to the cutting-edge welding process that reduces seams and makes cleaning easier, PAX puts performance first. They’ve partnered with 3M to perfect reflective surfaces for better visibility, and the bright grey interior makes finding gear fast and effortless, even in low light. With over 200 designs, PAX bags are made to suit your role, needs, and environment. And thanks to their modular system, many bags work seamlessly together, no matter the setup.PAX doesn’t chase trends. Their designs stay consistent, so once you know one, you know them all. And if your bag ever takes a beating? Their in-house repair team will bring it back to life.PAX – built to perform, made to last.Learn more at ⁠https://www.pax-bags.com/en/⁠

In this episode, Laura Hall reflects on a six-month journey as a volunteer with a Search and Rescue (SAR) team operating in a remote region of Colorado, offering listeners a grounded insight into the realities of wilderness emergency response. The discussion outlines the breadth of skills required to function effectively in SAR, from technical rope rescue and casualty care to drone operations, navigation, and complex inter-agency coordination.The conversation explores the intensity of training demands and the operational realities of callouts in challenging terrain, balancing professional competence with adaptability and teamwork. Beyond the technical elements, Laura highlights the strong sense of community that develops within volunteer SAR teams, where shared risk, service, and purpose foster deep local connections and lasting friendships.Practical safety considerations are also emphasised, particularly for those operating or recreating in the backcountry. Key takeaways include the importance of high-visibility clothing, robust personal protective equipment, and redundant communication systems to mitigate risk and improve survivability in austere environments.Ultimately, this episode functions both as a personal reflection on the value of volunteerism and as an honest guide to the operational, human, and safety realities of search and rescue work in wilderness settings. You can read the blog here: https://highadventurehealthcare.substack.com/p/six-months-of-sar⁠This episode is sponsored by PAX: The gold standard in emergency response bags.When you’re working under pressure, your kit needs to be dependable, tough, and intuitive. That’s exactly what you get with PAX. Every bag is handcrafted by expert tailors who understand the demands of pre-hospital care. From the high-tech, skin-friendly, and environmentally responsible materials to the cutting-edge welding process that reduces seams and makes cleaning easier, PAX puts performance first. They’ve partnered with 3M to perfect reflective surfaces for better visibility, and the bright grey interior makes finding gear fast and effortless, even in low light. With over 200 designs, PAX bags are made to suit your role, needs, and environment. And thanks to their modular system, many bags work seamlessly together, no matter the setup.PAX doesn’t chase trends. Their designs stay consistent, so once you know one, you know them all. And if your bag ever takes a beating? Their in-house repair team will bring it back to life.PAX – built to perform, made to last.Learn more at ⁠https://www.pax-bags.com/en/⁠

Professor David K. Menon joins us for an in-depth exploration of Traumatic Brain Injury (TBI). As the Founding Director of the Neurosciences Critical Care Unit at Addenbrooke’s Hospital, Professor Menon has been instrumental in shaping modern understanding of TBI physiology, monitoring, and management.In this episode, we break down intracranial pressure physiology in a way that translates directly to roadside decision-making, examining how brain swelling, cerebral perfusion, and autoregulation respond to early interventions. We focus on hypotension and hypoxia, the two most powerful drivers of secondary brain injury, and why the pre-hospital phase represents a critical window to influence outcomes long before CT imaging or neurosurgical care.We also explore the evidence for pre-hospital hypertonic therapy, discussing when it may be beneficial, where its limitations lie, and how it should (and should not) fit into contemporary practice. Practical considerations around airway management and ventilation are covered, including CO₂ targets, RSI decision-making, and strategies to avoid iatrogenic harm.Finally, we look ahead to emerging research and evolving concepts in TBI care, new physiological insights, changing targets, and innovative approaches aimed at reducing secondary brain injury, highlighting what pre-hospital clinicians should be thinking about now and in the years to come.Relevant resources and research networks:TBI-Reporter: https://tbi-reporter.uk/CENTER-TBI (Collaborative European NeuroTrauma Effectiveness Research in TBI): https://www.center-tbi.eu/This episode is essential listening for anyone involved in pre-hospital, retrieval, or critical care treating patients with traumatic brain injury. You can see more from David here: https://www.youtube.com/watch?v=7PhIGMpEpGQThis episode is sponsored by PAX: The gold standard in emergency response bags.When you’re working under pressure, your kit needs to be dependable, tough, and intuitive. That’s exactly what you get with PAX. Every bag is handcrafted by expert tailors who understand the demands of pre-hospital care. From the high-tech, skin-friendly, and environmentally responsible materials to the cutting-edge welding process that reduces seams and makes cleaning easier, PAX puts performance first. They’ve partnered with 3M to perfect reflective surfaces for better visibility, and the bright grey interior makes finding gear fast and effortless, even in low light. With over 200 designs, PAX bags are made to suit your role, needs, and environment. And thanks to their modular system, many bags work seamlessly together, no matter the setup.PAX doesn’t chase trends. Their designs stay consistent, so once you know one, you know them all. And if your bag ever takes a beating? Their in-house repair team will bring it back to life.PAX – built to perform, made to last.Learn more at ⁠https://www.pax-bags.com/en/⁠