Statewide and Regional Variation in Hospice and Palliative Care Protocols in Emergency Medical Services in the United...

The objective of this study was to assess the prevalence and characteristics of hospice and palliative care (HPC) protocols in emergency medical services (EMS) systems across the United States (U.S.), including both statewide and city-level protocols.

We conducted a cross-sectional review of publicly available EMS protocols from all 50 U.S. states and the District of Columbia, as well as the 50 most populous U.S. cities. Protocols were obtained between July and November 2024 using the centralized platform EMSProtocols.org and supplemental public sources. Protocols were included if they referenced hospice or palliative care-related terms ("hospice," "palliative," "comfort care," "end-of-life," "terminal illness"). Hospice protocols were included only if the term "hospice" appeared explicitly. Data were abstracted using a standardized form developed around several best-practice protocol features informed by the 2023 National Association of EMS Physicians and the American Academy of Hospice and Palliative Medicine joint position statement. Descriptive statistics were used to analyze the prevalence and content of identified protocols.

Of 101 jurisdictions reviewed, 62 EMS protocols were available for analysis (31 statewide and 31 city-level). Among these, 24.2% (15/62) included a hospice protocol and 25.8% (16/62) included a palliative care protocol. Among hospice protocols, 80.0% included orders for pain medication, 80.0% addressed general symptom management, 73.3% recommended contacting hospice agencies, and 86.7% included guidance on transport decisions. Among hospice protocols, 33.3% permitted EMS clinicians to administer medications from hospice emergency kits. Only one palliative care protocol addressed naloxone use, advising against its routine administration in end-of-life symptom management.

Across the U.S., HPC protocols remain inconsistently integrated into EMS systems. Fewer than one in four reviewed protocols included any HPC-specific guidance, and most lacked comprehensive components recommended by national guidelines. Broader adoption of HPC protocols and alignment with expert recommendations may improve the delivery of compassionate, goal-concordant care to a growing population of seriously ill patients in the out-of-hospital setting.