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Abstract

Background:

Emergency medical services (EMS) encounters with palliative care patients present unique operational challenges. As EMS providers increasingly care for individuals with life-limiting illnesses, understanding the intersection of emergency care and palliative medicine has become essential to optimizing healthcare delivery.

Objective:

This study examines EMS operational metrics, resource allocation patterns, and clinical outcomes among palliative care patients in Thailand.

Methods:

This retrospective analysis study investigated operational times, resource utilization, and clinical outcomes in palliative care patients utilizing EMS services, derived from electronic medical records and EMS documentation. This study was conducted at the Srinagarind Hospital EMS unit from October 2019 to September 2024. All patients diagnosed with palliative care (ICD-10 code Z51.5) who utilized EMS services were included.

Results:

Palliative care patients represented 6.9% (N = 340) of total EMS utilization (N = 4520), with cases increasing from 51 patients (15.0%) in 2019–2020 to 89 patients (26.2%) in 2023–2024. The median age was 72 years, with 62.9% male patients. Palliative care patients demonstrated significantly prolonged EMS operational times: activation (1.51 min vs 1.27 min), response (10.21 min vs 9.35 min), and scene time (22.05 min vs 10.02 min, p < 0.001). Resource utilization showed higher rates of pain medication administration (30.88% vs 7.79%) and exclusive use of comfort-focused interventions. Patient outcomes revealed significantly higher discharge rates.

Conclusion:

Palliative care patients utilizing EMS services represent a distinct population requiring specialized operational approaches. Extended scene times reflect appropriate symptom-focused care delivery rather than rapid transport protocols. Higher discharge rates validate the EMS role as a symptom management bridge.

Keywords

allocative efficiency palliative care prehospital emergency care response time

Introduction

The World Health Organization defines palliative care as a strategy aimed at improving the quality of life for patients and their families facing challenges associated with life-limiting illnesses.^1–3 Palliative care is essential for a wide range of conditions. The majority of adults requiring palliative care suffer from chronic illnesses such as cancer, chronic kidney disease, chronic respiratory disease, cardiovascular disease, diabetes, and immunocompromised conditions.^4–8

Emergency medical services (EMS) encounters with palliative care patients present unique clinical challenges that directly impact EMS operations, resource utilization, and patient outcomes. As EMS providers increasingly serve as frontline responders for patients with life-limiting illnesses, understanding the intersection of emergency care and palliative medicine has become essential to optimizing both acute interventions and end-of-life care delivery. The operational challenges facing EMS providers caring for palliative patients are multifaceted, involving a complex interaction of acute medical intervention, end-of-life planning, and healthcare resource management, which has drawn increasing attention in the context of contemporary healthcare delivery.^9–12

Recent studies highlight rising EMS utilization rates among palliative care patients, with significant implications for healthcare resource allocation. In addition, the clinical complexities of delivering emergency care to this population have been well documented through interviews with EMS personnel, revealing several persistent challenges. These include difficulties interpreting advance directives during emergencies, uncertainty regarding appropriate interventions for comfort-focused care, and communication barriers between EMS providers and palliative care teams, all of which hinder optimal care delivery.^13–15 The uncontrolled progression of disease, inadequate symptom management, caregiver anxiety, and restricted access to the palliative care team often result in visits to the emergency department and utilization of ambulance services. At Srinagarind Hospital, comprehensive multidisciplinary palliative care is typically provided during daytime hours; outside of these hours, a dedicated specialist palliative care team may not be routinely accessible. Care outside of daytime hours is typically restricted to an on-call system that offers telephone or telemedicine consultations and occasionally limited home nursing assistance. This limited after-hours capacity likely leads to heightened EMS activation for symptom management. This situation poses specific difficulties for EMS providers, who must navigate the delicate balance between administering appropriate acute interventions and honoring patients’ end-of-life care preferences and directives. As global healthcare systems face aging populations and rising chronic disease burdens, the frequency of emergency service utilization by palliative care patients has become a critical indicator of care coordination effectiveness and overall resource efficiency.^16–18

In Thailand, these challenges are compounded by unique cultural and systemic factors.^19–21 The country’s healthcare system has undergone significant transformation since the establishment of the National Institute for Emergency Medicine in 2008, which has played a central role in developing standardized EMS protocols across diverse geographic regions. However, the integration of palliative care principles into EMS operations has lagged behind other areas of healthcare development.

This gap may be attributed to several factors, including limited palliative care education among Thai EMS personnel and the influence of the Buddhist cultural context, which significantly shapes palliative care delivery and EMS utilization patterns. Cultural attitudes toward death and dying within Thai families, along with Buddhist beliefs in karma, often lead to delayed help-seeking behaviors, including hesitation in activating EMS.

Recognizing the complex relationship between EMS utilization and palliative care delivery is crucial for healthcare administrators, policymakers, and clinical practitioners aiming to enhance resource allocation while ensuring high-quality, patient-centered care. This study examines the operational metrics associated with EMS utilization among palliative care patients, analyzes current resource allocation patterns, and evaluates patient outcomes. This comprehensive analysis seeks to identify opportunities for system improvement that can enhance operational efficiency and the quality of end-of-life care delivery.

Methods

Study design and setting

This retrospective analytic investigation was conducted at the EMS unit of Srinagarind Hospital, Faculty of Medicine, Khon Kaen University, Thailand, using computerized medical data from October 2019 to September 2024. The primary objective was to compare EMS operational times, resource utilization, and patient outcomes between palliative care patients and non-palliative care EMS patients who accessed services during this period. The secondary objective was to explore the characteristics of palliative care patients who used EMS services.

EMS in the Khon Kaen University Hospital area are provided by the Srinagarind EMS unit. The hospital conducts over 2500 EMS operations annually, serving as the principal teaching center for emergency physicians and EMS personnel in the region and maintaining an academic affiliation with the university.

The Srinagarind EMS unit performs more than 2500 operational deployments annually, encompassing both basic and advanced EMS operations. Basic EMS operations deliver fundamental emergency care for stable patients, whereas advanced EMS operations (approximately 1000 annually) administer sophisticated medical interventions for critically ill or injured individuals. The EMS unit is operated by a dispatch center that manages six van ambulances, two motorcycle ambulances, and a telemedicine service, offering round-the-clock online medical guidance. Each EMS operation is staffed by a team of three to five personnel, including emergency physicians, nurses, and emergency medical technicians. Each EMS operation is staffed by a minimum of three personnel, with team size increasing to four or five for higher‑acuity responses. The unit functions according to hospital-based clinical protocols and is supervised by telemedicine physicians from the dispatch center around the clock. Standard competencies for EMS personnel encompass intravenous access, supplemental oxygen administration, electrocardiography, the dispensation of hospital-sanctioned medications (including analgesics and other symptom-relief agents under physician supervision), and the execution of fundamental comfort-oriented procedures (such as nasogastric and Foley catheter insertion when warranted). Formalized, specialized palliative care training is not included in the standard national EMS certification at our institution. The principles of palliative care are predominantly incorporated via on-the-job supervision. Khon Kaen University facilitated educational sessions led by the hospital’s palliative care team, which provides comprehensive training at the Karunruk Palliative Care Center, including workshops centered on symptom management for physicians and nurses. However, attendance at these courses is contingent upon the preferences of each EMS staff member, rather than being a requirement for certification.

Participants

The study included all patients admitted to the EMS unit from October 1, 2019 to September 30, 2024. Inclusion criteria encompassed patients who utilized EMS services and were diagnosed as palliative care patients, identified using the International Classification of Diseases (ICD-10) code Z51.5 (palliative care) in their medical records. Patients with insufficient data or those transferred to another institution were excluded.

Patients receiving palliative care in our hospital were primarily identified via the ICD-10 code Z51.5 recorded in the electronic medical record (EMR) by our palliative care team. We chose Z51.5 as the primary inclusion criterion because it clearly denotes that palliative care services were provided or intended, yielding a high-specificity cohort for the analysis of EMS encounters specifically classified as palliative.

Data gathering

Patient variables were extracted from EMRs using the Health Object Program^®, an authorized EMR system, with each patient assigned an anonymous identifier.

EMS operation times, medication, and procedures performed at the scene and during transport were extracted from EMS records. We a priori categorized interventions as symptom- or comfort-focused if their primary purpose is symptom relief in palliative practice (examples used in this study: analgesic administration, nasogastric tube insertion, and urinary (Foley) catheter insertion).

ED disposition was categorized as discharged home (discharge from the ED to the patient’s home/nursing care after evaluation/treatment), admitted to the hospital, transferred to another hospital, or death in the ED. Outcome percentages reported in Results and Table 2 are presented as proportions of patients transported to the ED.

Shift categories have been defined based on the EMS dispatch timestamp (local time) as follows: night = 00:00–07:59, morning = 08:00–15:59, and afternoon = 16:00–23:59. Each call was allocated to a shift according to the documented dispatch time.

Data were compiled and organized into a research database by two independent investigators, who reviewed and removed any duplicate entries. A second round of data entry was then conducted. In cases of discrepancies, a senior emergency physician was consulted to verify and finalize the data.

Statistical analysis

The minimum sample size (n = 340) was estimated using the primary outcome and effect sizes reported in prior studies.^22,23 We assumed a two‑sided significance level (α) of 0.05 and statistical power (1 − β) of 0.80. The calculation used the standard formula for comparison of two proportions with the repeated‑measures approach²⁴ and the effect size observed in the cited studies. Based on these assumptions, the minimum required sample was estimated to be 340 participants. To allow for exclusions and incomplete records, we inflated this figure modestly during study planning; the final analytic sample (n = 4520) substantially exceeded the calculated minimum.

Statistical analysis was performed using IBM SPSS for Windows version 27.0 (SPSS Inc., Chicago, IL, USA) under a Khon Kaen University license. For univariate analysis, the Chi-squared test was used to compare groups, and the two-sample t test was applied to numerical data. A two-tailed p value of <0.05 was considered statistically significant. Unless otherwise specified, continuous variables are reported as mean and interquartile range (IQR), while categorical variables are presented as number (n) or frequency (percent).

Results

Baseline characteristics of studied cases

During the 5-year study period, a total of 340 palliative care patients (6.9%) accessed EMS services at Srinagarind Hospital. Case distribution showed a gradual increase over time, from 51 of 340 palliative patients (15.0%) in 2019–2020 to 89 of 340 palliative patients (26.2%) in 2023–2024.

The median age of palliative care patients was 72 years (IQR: 70–82; p = 0.861). Male patients comprised 214/340 (62.9%) of the study population cohort. The majority of EMS calls originated from patients’ residences (88.2%), while 11.8% came from nursing care facilities (p = 0.021).

Regarding operational timing, morning shifts accounted for the highest proportion of EMS calls at 60.3%, followed by afternoon shifts at 38.2%, and night shifts at 1.5%. The leading cause for EMS activation among palliative care patients was fatigue (29.7%), followed by pain (26.5%) and dyspnea (12.1%). Cancer was the most common primary diagnosis, affecting 29.4% of the study cohort. Details are presented in Table 1.

Table 1.

Participant information (N = 340).

Variables	2019–2020 (N = 51)	2020–2021 (N = 52)	2021–2022 (N = 73)	2022–2023 (N = 75)	2023–2024 (N = 89)	p Value
Age (year), median (IQR)	72 (70, 82)	75 (71, 84)	68 (65, 81)	71 (68, 80)	77 (75, 85)	0.861
Male, %	30 (58.82)	31 (59.61)	45 (61.64)	45 (60.00)	56 (62.92)	0.912
Case location, %						0.021
Home	47 (92.16)	45 (86.54)	65 (89.04)	66 (88.00)	77 (86.52)
Nursing care	4 (7.84)	7 (13.46)	8 (10.96)	9 (12.00)	12 (13.48)
Operation times, %						0.012
Morning shift	29 (56.87)	32 (61.53)	51 (69.86)	46 (61.33)	48 (53.93)
Afternoon shift	21 (41.17)	20 (38.47)	21 (28.77)	29 (38.67)	39 (43.82)
Night shift	1 (1.96)	0 (0)	1 (1.37)	0 (0)	2 (2.25)
Reason for EMS call, %						0.026
Fatigue	16 (31.37)	17 (32.69)	22 (30.14)	19 (25.33)	26 (29.21)
Pain	10 (19.61)	15 (28.85)	20 (27.39)	24 (32.00)	23 (25.84)
Difficult breathing	6 (11.76)	5 (9.62)	9 (12.33)	10 (13.33)	11 (12.36)
Alteration of consciousness	5 (9.80)	3 (5.77)	7 (9.59)	10 (13.33)	6 (6.74)
Cannot feed	3 (5.88)	7 (13.46)	6 (8.22)	6 (8.00)	13 (14.61)
Fall	1 (1.96)	2 (3.85)	2 (2.74)	3 (4.00)	2 (2.25)
Other	0 (0)	3 (5.77)	7 (9.59)	3 (4.00)	8 (8.99)
Diagnosis, %						0.028
Cancer	16 (31.37)	17 (32.69)	23 (31.51)	20 (26.67)	26 (29.21)
Cardiovascular	7 (13.73)	10 (19.23)	12 (16.44)	15 (20.00)	18 (20.22)
Chronic respiratory disease	8 (15.69)	6 (11.54)	11 (15.07)	13 (17.33)	15 (16.85)
Chronic kidney disease	10 (19.61)	9 (17.31)	12 (16.44)	11 (14.67)	13 (14.61)
Chronic liver disease	0 (0)	5 (9.62)	6 (8.22)	6 (8.00)	8 (8.99)
Neurological disease	10 (19.61)	5 (9.62)	8 (10.96)	5 (6.67)	5 (5.62)
Immunocompromised disease	0 (0)	0 (0)	0 (0)	3 (4.00)	3 (3.37)
Other	0 (0)	0 (0)	1 (1.37)	2 (2.67)	2 (2.25)

IQR: interquartile range; EMS: emergency medical services.

Data were presented as percentage (%) for categorical variables and median (IQR) for continuous variables. All p values are two‑sided. Statistical significance was set at p < 0.05.

Outcomes

In Table 2, a comparative analysis of palliative care patients (N = 340) and non-palliative care patients (N = 4520) revealed significant differences in EMS operational metrics (p < 0.001). Palliative care patients demonstrated prolonged durations across all operational phases: activation time (median 1.51 min vs 1.27 min), response time (median 10.21 min vs 9.35 min), and significantly extended scene time (median 22.05 min vs 10.02 min).

Table 2.

Primary outcome of the study.

Variables	Non-palliative care patients (N = 4520)	Palliative care patients (N = 340)	p Value
EMS operational time, median (IQR), minute			<0.001
Activation time	1.27 (1.01, 1.32)	1.51 (1.12, 1.75)	0.064
Response time	9.35 (8.13, 10.13)	10.21 (9.51, 11.25)	0.210
Scene time	10.02 (7.09, 12.26)	22.05 (20.15, 24.35)	<0.001
Resources utilized in EMS, %			<0.001
Intravenous line placement	3723 (82.37)	278 (81.76)	0.589
Pain medication	352 (7.79)	105 (30.88)	<0.001
Supplemental oxygen	3672 (81.24)	52 (15.29)	<0.001
Electrocardiography	2110 (46.68)	5 (1.47)	<0.001
Other medication	3975 (87.94)	22 (6.47)	<0.001
Nasogastric, Foley insertion	0 (0)	31 (9.12)	<0.001
Missing data	227 (5.02)	0 (0)	<0.001
Patients transported, %	4202 (92.96)	278 (81.76)	<0.001
Outcomes of patients at ED, %			<0.001
Discharge home/nursing care	1252 (29.79)	228 (82.01)	<0.001
Admit in hospital	926 (22.04)	38 (13.67)	0.001
Transfer to other hospital	1714 (40.79)	0 (0)	<0.001
Death at ED	310 (7.38)	12 (4.32)	0.056

IQR: interquartile range; EMS: emergency medical services; ED: emergency department.

Resource utilization patterns also differed significantly between the two groups (p < 0.001). The rates of intravenous line placement were comparable between the groups (278/340 (81.8%) vs 3723/4520 (82.4%); p = 0.589), while palliative care patients received analgesics significantly more frequently than non-palliative patients (105/340 (30.9%) vs 352/4520 (7.8%); p < 0.001).

Emergency department outcomes differed significantly (p < 0.001). Among patients transported to the ED, palliative care patients were more frequently discharged home (228/278; 82.01%) than non‑palliative patients (1252/4202; 29.79%). Hospital admission was less common in transported palliative patients (38/278; 13.67%) than in transported non‑palliative patients (926/4202; 22.04%).

Data were presented as percentage (%) for categorical variables and median (IQR) for continuous variables. All p values are two‑sided. Statistical significance was set at p < 0.05.

Discussion

This 5-year retrospective analysis offers the first comprehensive examination of EMS utilization patterns among palliative care patients in Thailand, revealing distinct operational characteristics with significant implications for healthcare resource allocation and service delivery.

The analytic sample (N = 4860) is smaller than the total operational volume (over 2500 deployments per year) due to our inclusion criteria, which limited analysis to encounters recorded in the hospital EMR that led to ED assessment or a documented non-transport outcome. This methodological decision emphasized the comprehensiveness of clinical data, yet indicates that the sample does not reflect all operational deployments. Our study demonstrated the notable rise in palliative care EMS encounters from 15.0% to 26.2% throughout the study period, likely indicating enhanced integration of palliative care within EMS operations, improved recognition and documentation (ICD‑10 Z51.5), and increased access to palliative services within the Thai healthcare system, aligning with global trends observed in more developed healthcare systems.^25,26

The number of palliative patients visiting the ED during night shifts was minimal (total n = 4), leading to zero counts for two study years. This may stem from various factors, including health-system and cultural influences: (1) Thailand’s primary care network, comprising health-promoting hospitals, subdistrict health centers, and village health volunteers, often assists families by providing advice or basic care, thereby diminishing the necessity for overnight ambulance dispatch; (2) Numerous hospitals and palliative teams offer after-hours telephone consultations or on-call nursing services that can manage symptoms remotely, particularly for known palliative patients; (3) Cultural and religious (Buddhist) beliefs may encourage a greater acceptance of suffering or a preference for dying at home, prompting families to endure symptoms overnight instead of immediately contacting EMS; and (4) EMS dispatch may prioritize life-threatening calls during nighttime hours, leading dispatchers or on-call clinicians to recommend non-ambulance alternatives (such as phone consultations or home nursing) for palliative patients with non-acute symptoms, thus reducing nighttime call volumes. In addition, our inclusion criteria excluded certain operational deployments that were not documented in the hospital’s EMR.

The comparatively low proportion of cancer diagnoses in our EMS palliative cohort (29.4%) contrasts with numerous hospice or cancer center studies that report approximately 75% of oncology patients. A multitude of factors probably clarify this discrepancy, as (1) our inclusion criterion was based on the ICD-10 code Z51.5 documented for any EMS encounter, resulting in a comprehensive, high-specificity palliative cohort encompassing non-oncologic chronic diseases typically addressed with palliative strategies in Thailand. (2) The sampling frame (EMS encounters documented in a tertiary hospital EMR) targets patients experiencing acute symptom crises; noncancer chronic conditions frequently result in abrupt exacerbations that necessitate ambulance utilization. (3) Local care pathways and coding practices may vary: cancer patients in certain regions are more likely to receive hospice or home-care services or specialized transport that circumvents EMS, whereas noncancer palliative patients may more commonly depend on ambulance services.

In terms of EMS operational metrics, the between‑group differences in the operational time measures were statistically significant; in particular, the scene time difference was highly significant (p < 0.001). The study identified the extended scene time observed in palliative care patients (22.05 min vs 10.02 min) as a critical finding with multifaceted implications. This aligns with previous studies^{6,22,23,27–29} reporting that EMS providers spend significantly more time on scene, particularly with patients facing serious illnesses. The nearly twofold increase reflects the complex decision-making required when caring for patients with advance directives, the need for thorough communication with family members regarding care goals, and the time needed for symptom-focused interventions rather than rapid stabilization and transport. Although this extended scene time may initially appear to hinder operational efficiency, it represents appropriate, patient-centered care consistent with palliative care principles.

Emergency crisis cards or equivalent advance-directive communication instruments signify a promising method to enhance on-scene decision-making and facilitate goal-concordant care. Recent evidence³⁰ indicates that specialized outpatient palliative care programs that enable clear, transferable documentation of patient preferences and emergency directives correlate with reduced hospitalizations and improved alignment of care with patient objectives. The implementation of crisis cards or a standardized emergency summary may diminish the duration EMS personnel require to determine family preferences, reduce unnecessary transport, and facilitate the prompt provision of comfort-oriented interventions. Although these tools were not regularly utilized in our cohort and therefore could not be assessed in this context, their application necessitates prospective evaluation as a viable intervention to enhance both operational efficiency and patient-centered outcomes.

The distinct resource utilization patterns observed in this study offer important insights into the specialized needs of palliative care patients. The fourfold increase in pain medication administration (30.88% vs 7.79%) underscores the emphasis on symptom management, aligning with palliative care principles and supported by extensive international literature.^4,7,31–34 The consistency of these findings across diverse healthcare systems and geographic regions reinforces that elevated pain medication use in palliative care EMS encounters reflects evidence-based, patient-centered care that appropriately prioritizes symptom relief over conventional emergency interventions.

The significantly different emergency department outcomes—higher discharge rates (82.01% vs 29.79%) and lower admission rates (13.67% vs 22.04%) among palliative care patients. Our institution has not implemented a formal, written palliative care admission protocol; instead, the palliative care team made individual determinations regarding disposition. In practice, patients who explicitly preferred to die in the hospital or required inpatient-level care were prioritized for admission, while those whose needs could be addressed with symptom-focused interventions typically received treatment in the emergency department and were either discharged home or managed at home with outpatient palliative follow-up. In northeastern Thailand, many rural patients prefer to die at home due to religious beliefs and Buddhist principles. The literature^22,23,35 consistently shows that high discharge rates and low admission rates among palliative care patients in emergency settings reflect appropriate, goal-concordant care rather than inadequate treatment. These patterns indicate the effective role of emergency services as “symptom management bridges,” delivering acute care while enabling return to preferred care environments.³⁶ The evidence^36–38 strongly supports the conclusion that a robust community palliative care infrastructure is essential for maintaining these care transitions. Coordinated investment in both emergency and community-based palliative care is necessary to optimize patient outcomes and ensure efficient resource utilization.

In terms of the characteristics of palliative care patients who used the EMS system, the predominance of symptom-driven EMS calls—particularly for fatigue (29.7%) and pain (26.5%)—underscores the critical role of symptom management in palliative care delivery. These findings are consistent with international literature³⁶ demonstrating that inadequate symptom control is a key driver of emergency service utilization among end-of-life patients. A 2019 study³⁷ analyzing 1547 hospice patient EMS encounters found that pain (31.2%) and weakness/fatigue (28.6%) were the most common presenting complaints, closely mirroring our results. That study concluded that “symptom crises, rather than acute medical emergencies, constitute the primary reason for EMS activation in palliative care populations.” The observed variation in diagnostic categories over time, with cancer remaining the leading indication (29.4%), reflects the evolving landscape of chronic disease management and the expanding scope of palliative care beyond oncology to include cardiovascular, respiratory, neurological, and renal conditions. The predominance of home-based EMS calls (88.2%) among palliative care patients highlights the cultural preference for end-of-life care in familiar environments, consistent with Buddhist principles that emphasize peaceful dying processes.^13,38,39 This finding has important implications for EMS training and resource deployment, as providers must be equipped to deliver care in diverse home settings with potentially limited equipment and space. The operational differences identified in this study underscore the need for specialized EMS training in palliative care. EMS providers require enhanced education in interpreting advance directives, communicating with families during crises, and delivering symptom-focused interventions.^2,4,6 The exclusive use of nasogastric and Foley catheter insertions among palliative care patients (9.12%) suggests that EMS personnel are appropriately utilizing comfort-oriented procedures, though this also highlights the need for standardized protocols and training in these interventions.

The predominance of EMS calls during the morning shift (60.3%) may indicate various local and measurement variables. Family caregivers and regular home-care visits are more prevalent in the morning, thus symptom deterioration that commences overnight is frequently identified and addressed upon caregivers’ awakening. Routine morning care, such as feeding, repositioning, and medication administration, frequently uncovers issues that necessitate EMS activation. Moreover, current primary care networks and on-call palliative services often offer telephone or home nursing assistance overnight, which can address or postpone non-urgent issues until daytime. This temporal pattern has important implications for EMS staffing and resource allocation, especially given the extended scene times typically required for palliative care patients.

This comprehensive analysis establishes that palliative care patients utilizing EMS services represent a distinct population with specialized needs, necessitating fundamental adaptations to improve the quality of EMS delivery.^{22–24,35,37,40,41} The effective integration of palliative care principles into EMS requires coordinated investment in training, infrastructure, and community-based support systems, ultimately enhancing both operational efficiency and patient-centered care within modern healthcare systems.^42–45 Future research should explore patient and family satisfaction outcomes associated with palliative care EMS encounters, evaluate the impact of specialized training programs on care quality and provider confidence, and assess the cost-effectiveness of adapted EMS models for palliative care delivery. Longitudinal studies examining the relationship between the development of community palliative care infrastructure and patterns of emergency service utilization would offer critical insights for healthcare system planning.

Limitations

This study has several limitations that should be acknowledged when interpreting the findings. First, the retrospective design inherently limits the ability to establish causal relationships and may introduce selection bias and issues related to missing data. Second, as a single-center study conducted at a university-affiliated hospital, the findings may not be generalizable to other healthcare settings, particularly non-academic hospitals or rural facilities with differing resource availability and staffing models. Third, the study’s geographical focus on the Khon Kaen University Hospital catchment area may not adequately represent the diverse cultural, socioeconomic, and healthcare access patterns present in other regions of Thailand or other parts of the world. Disparities between rural and urban areas in palliative care access and EMS utilization were not fully captured. Fourth, the identification of palliative care patients was based solely on ICD-10 code Z51.5, which may lead to under-identification of patients receiving informal palliative care and over-identification of those coded as palliative but not actively receiving such services. Future studies should validate ICD-based case ascertainment against a clinical “gold standard” and consider multi-source case-finding approaches to reduce misclassification. Fifth, the study did not include patient and family outcome measures, such as satisfaction with care, quality of life assessments, or goal-concordance of care—factors that are essential for evaluating the quality of palliative care delivery. Sixth, we did not perform a direct comparison of presenting complaints between palliative and non‑palliative patients because these complaint categories were only consistently coded for the palliative cohort. Anxiety, caregiver distress, and indicators of insufficient community care were not routinely recorded as separate presenting complaints and may therefore be under‑represented in our dataset.

Conclusion

Our study revealed significant differences in EMS operational metrics, with palliative care patients requiring extended scene times that reflect appropriate symptom-focused care delivery rather than adherence to rapid transport protocols. The specialized needs of palliative care patients were emphasized by resource utilization patterns, which indicated higher rates of analgesic administration and specific procedures (nasogastric and Foley catheter insertions) that were only recorded in the palliative cohort in our dataset. These patients were also more likely to receive symptom-directed care. Patient outcomes demonstrated significantly higher emergency department discharge rates and lower admission rates for palliative care patients, validating the role of EMS as “symptom management bridges” rather than gateways to hospitalization.

Footnotes

The authors would like to express their sincere gratitude to Josh Macknick for serving as an English consultant. We express our appreciation to Lap Woon Cheung for supervising our research. In addition,we are grateful to Korakot Apiratwarakul for acquiring the funding.

ORCID iDs

Kamonwon Ienghong

Korakot Apiratwarakul

Ethical considerations

This study adhered to the principles of the Declaration of Helsinki and the guidelines of Good Clinical Practice. The Ethics Committee for Human Research at Khon Kaen University approved the study (HE671677). To ensure confidentiality,all identifiers were removed from the collected data.

Consent to participate

Informed consent to participate was waives due to the retrospective study design.

Author contributions

Kamonwon Ienghong: Conceptualization;Data curation;Formal analysis;Funding acquisition;Investigation;Methodology;Project administration;Resources;Supervision;Validation;Visualization;Writing – original draft;Writing – review & editing.

Waritsara Aimchai: Conceptualization;Data curation;Formal analysis;Investigation;Methodology;Resources;Validation;Writing – original draft.

Lap Woon Cheung: Conceptualization;Data curation;Formal analysis;Investigation;Methodology;Project administration;Supervision;Validation;Writing – original draft.

Chatkhane Pearkao: Conceptualization;Formal analysis;Investigation;Methodology;Project administration;Writing – original draft.

Korakot Apiratwarakul: Conceptualization;Data curation;Formal analysis;Funding acquisition;Investigation;Methodology;Project administration;Resources;Supervision;Validation;Visualization;Writing – original draft;Writing – review & editing.

Funding

The authors disclosed receipt of the following financial support for the research,authorship,and/or publication of this article: This study was facilitated by the Fundamental Fund of Khon Kaen University,which received funding from the National Science,Research and Innovation Fund (NSRF).

Declaration of conflicting interests

The authors declared no potential conflicts of interest with respect to the research,authorship,and/or publication of this article.

Data availability statement

To protect the privacy of the study participants,no original data could be published. The data supporting the results of this study and additional material are available upon request from the authors.

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