title: "We Are Strangers Walking Into Their Life-Changing Event": How Prehospital Providers Manage Emergency Calls at the End of Life.
abstract: BACKGROUND
  Emergency 911 calls are often made when the end stage of an advanced illness is accompanied by alarming symptoms and substantial anxiety for family caregivers, particularly when an approaching death is not anticipated. How prehospital providers (paramedics and emergency medical technicians) manage emergency calls near death influences how and where people will die, if their end-of-life choices are upheld and how appropriately health care resources are used.
  
  
  OBJECTIVE
  The purpose of this study was to explore and describe how prehospital providers assess and manage end-of-life emergency calls.
  
  
  METHODS
  In-depth and in-person interviews were conducted with 43 prehospital providers. Interviews were audiotaped, transcribed, and entered into ATLAS.ti for data management and coding. Qualitative data analysis involved systematic and axial coding to identify and describe emergent themes.
  
  
  RESULTS
  Four themes illustrate the nature and dynamics of emergency end-of-life calls: 1) multifocal assessment (e.g., of the patient, family, and environment), 2) family responses (e.g., emotional, behavioral), 3) conflicts (e.g., missing do-not-resuscitate order, patient-family conflicts), and 4) management of the dying process (e.g., family witnessed resuscitation or asking family to leave, decisions about hospital transport). After a rapid comprehensive multifocal assessment, family responses and the existence of conflicts mediate decision making about possible interventions.
  
  
  CONCLUSIONS
  The importance of managing symptom crises and stress responses that accompany the dying process is particularly germane to quality care at life's end. The results suggest the importance of increasing prehospital providers' abilities to uphold advance directives and patients' end-of-life wishes while managing family emotions near death.
authors.affiliation: University at Buffalo School of Social Work, Buffalo, New York, USA. Electronic address: dwaldrop@buffalo.edu.
authors.forename: Deborah P
authors.initials: DP
authors.lastname: Waldrop
authors.affiliation: Department of Emergency Medicine, University at Buffalo School of Medicine, Buffalo, New York, USA; Department of Emergency Medicine, Erie County Medical Center, Buffalo, New York, USA.
authors.forename: Brian
authors.initials: B
authors.lastname: Clemency
authors.affiliation: Department of Emergency Medicine, Erie County Medical Center, Buffalo, New York, USA.
authors.forename: Heather A
authors.initials: HA
authors.lastname: Lindstrom
authors.affiliation: Doctor of Behavioral Health Program, Arizona State University, Phoenix, Arizona, USA.
authors.forename: Colleen
authors.initials: C
authors.lastname: Clemency Cordes
mesh_terms: D000328:Adult; D001291:Attitude of Health Personnel; D003220:Conflict, Psychological; D003430:Cross-Sectional Studies; D003643:Death; D004632:Emergency Medical Services / Q000379:methods*; D004634:Emergency Medical Technicians / Q000523:psychology*; D004777:Environment; D005190:Family / Q000523:psychology; D005260:Female; D006801:Humans; D007407:Interviews as Topic; D008297:Male; D026684:Personal Autonomy; D016414:Resuscitation Orders / Q000523:psychology; D013315:Stress, Psychological; D013727:Terminal Care / Q000379:methods* / Q000523:psychology*
keywords: End-of-life decision making; advance care planning; emergency medical services; emergency medical technicians; terminal care