Death and dying in prehospital care: what are the experiences and issues for prehospital practitioners, families and bystanders? A scoping review

Objective To identify the factors that shape and characterise experiences of prehospital practitioners (PHPs), families and bystanders in the context of death and dying outside of the hospital environment where PHPs respond. Design A scoping review using Arksey and O’Malley’s five-stage framework. Papers were analysed using thematic analysis. Data sources MEDLINE; Embase; CINAHL; Scopus; Social Sciences Citation Index (Web of Science), ProQuest Dissertations & Theses A&I (Proquest), Health Technology Assessment database; PsycINFO; Grey Literature Report and PapersFirst were searched from January 2000 to May 2019. Eligibility criteria for selecting studies Qualitative and mixed methods studies reporting the experiences of PHPs, families and bystanders of death and dying in prehospital settings as a result of natural causes, trauma, suicide and homicide, >18 years of age, in Europe, USA, Canada, Australia and New Zealand. Results Searches identified 15 352 papers of which 51 met the inclusion criteria. The review found substantial evidence of PHP experiences, except call handlers, and papers reporting family and bystander experiences were limited. PHP work was varied and complex, while confident in clinical work, they felt less equipped to deal with the emotion work, especially with an increasing role in palliative and end-of-life care. Families and bystanders reported generally positive experiences but their support needs were rarely explored. Conclusions To the best of our knowledge this is the first review that explores the experiences of PHPs, families and bystanders. An important outcome is identifying current gaps in knowledge where further empirical research is needed. The paucity of evidence suggested by this review on call handlers, families and bystanders presents opportunities to investigate their experiences in greater depth. Further research to address the current knowledge gaps will be important to inform future policy and practice.


STRENGTHS AND LIMITATIONS
 To our knowledge this is the first review to focus on practitioner, family and bystander experience of death and dying in pre-hospital care (PHC).
 The review will help to make better sense of pre-hospital practitioners, families and bystander experiences and to prioritise from these perspectives ways to improve these experiences through support and training.
 The search strategy aimed to balance sensitivity and precision and pragmatic decisions helped achieved this balance and to target studies most likely to be relevant; these decisions may also have increased the risk of missing relevant records.
 A focus on healthcare systems similar to that of the United Kingdom was intended to increase transferability of findings. However, differences in these systems may limit transferability. other services such as patient transport and NHS 111, a 24-hour online and telephone urgent care service. [3] In some UK regions services are delivered by other providers, including charities and private companies, but in line with NHS principles remain free at the point of access, with some limited exceptions in England. For example, it is a requirement for some overseas students to pay a NHS surcharge or take out private health cover. However, the system in the UK is not reflected worldwide. In Australia, other than in Queensland and Tasmania, ambulance services are covered either by private health insurance or are out of pocket, unless an individual is eligible for a concession such as those over 65 years of age, where cover is free, or in some states offered at a reduced rate. [4] Ambulance services in the United States are operated by private (for-profit and non-profit) and public entities, and with no free universal healthcare in the US are typically paid for by private health insurance or federally funded programmes such as Medicare and Medicaid. [5] Evidence suggests the nature of ambulance provision can influence the service provided. [6] In the UK there is an increasing demand for PHC services. [3,4] In England for the period 2014-15 the number of emergency 999 calls to ambulance switchboards totalled 9 million, a rise of over 500,000 from the previous year [7] an increase mirrored in other healthcare systems. [8,9] Factors contributing to increasing demand are complex and reflect the extent to which work carried out in PHC has been required to react to changes in other parts of the healthcare system. [10] For example, ageing populations with complex needs, [11,12] difficulties in accessing general practitioner (also known as primary care physician) services, [13] and greater patient expectations and how patients seek help, [14] have meant the remit of the service has changed. [15] As an evolving service pre-hospital practitioners (PHP)' work has become increasingly varied and complex requiring a clinically trained workforce comprising a variety of staffing combinations, such as medical dispatchers, doctors, paramedics, emergency medical technicians, and emergency care practitioners.
The nature of the work of PHPs can range from responding to time-critical emergencies for serious or life-threatening injuries or illnesses, such as cardiac arrests, calls that are less immediately time critical but still serious, to those not considered life threatening. Out of Hospital Cardiac Arrest (OHCA) is a lead cause of death in industrialised society, [16,17] and while it represents a small proportion of PHC (approximately 0.5% of calls to English ambulance services) national response targets place a significant strain on services. In England, during 2014, the ambulance service treated 28,729 cases of OHCA alone, [18] and evidence suggests numbers rising year on year. [19] Increasingly, the ambulance service also responds to calls for people who have life-limiting conditions and approaching the end of life (EoL). [20] As first responders to crises that immediately precede death, confronting death and dying is an intrinsic part of the work of PHPs. [21] When providing care to someone who is dying, or dies, they are often required to make challenging decisions and deal with the clinical and emotional aspects of a situation simultaneously. [22] This requires management of their own feelings and responses, as well others present including family and bystanders who may or may not have an established relationship with the person. In some countries PHPs can verify qualified PHPs to confirm death and cease resuscitation in the field. [23] Similarly, in the USA and Canada paramedics can confirm death on-scene. [24,25] This aspect of their work has the accompanying responsibility of informing relatives or others present that the patient has died.
The provision of care to someone who is dying, and their relatives, has been identified as one of the most stressful human experiences [22,26] and acknowledged as challenging for healthcare professionals generally. For those working in PHC, this may be more complex, partly because ambulance crews are immediately required to assess and respond to a situation, [26] and the transient nature of the job may not present opportunities to establish rapport with a dying patient or their relatives, which may have a lasting impact for survivor families into bereavement. However, little is known about the effects on families and others present, or support mechanisms in place for relatives or bystanders who witness an incident when a patient dies where PHPs attend. Similarly, while we know that PHPs encounter death and dying routinely in the course of their work, we understand less about the nature of this aspect of their job, the impact of dealing with death and dying, how they manage situations where a patient dies especially when they do not always have opportunities to debrief with their colleagues, [27] or their emotional, psychological, educational and training needs in relation to death and dying.
This review is needed to better inform our understanding about the experiences and needs of PHPs, families and bystanders in the pre-hospital context of death and dying in order to identify areas for further research.

Aim of the review
In this paper we present a scoping review that explores evidence guided by the question: What is known about the factors that shape and characterise experiences of PHPs, families, and bystanders in the context of death and dying outside of the hospital environment where PHPs respond?
Specific objectives were to: 1) Ascertain experiences of PHPs when providing care to patients, and supporting families and bystanders, and their own support and training needs.
2) Understand types of PHPs' behaviours and communication strategies enacted for family members and bystanders.
3) Explore families' and bystanders' experiences and needs and identify any existing support mechanisms.

DESIGN AND METHODS
A scoping review methodology [28][29][30] was selected as the most appropriate for systematically mapping the literature and identifying key themes, concepts and gaps in knowledge. We used Arksey and O'Malley's [31] five stage framework for scoping reviews which includes identifying the research question, identifying relevant literature, selection, charting the data and collating, summarising and reporting the results. We also used Levac et al's recommendations to strengthen methodological rigour. [32]

Searches and information sources
Searches were carried out in two stages. Stage 1 comprised an initial search in MEDLINE (OvidSP). The population/problems, exposure/issue, outcome/themes (PEO) framework (see Table 1

Exclusion and inclusion criteria
Papers were selected using specific eligibility criteria outlined in Table 2. Only literature focusing on adult death and dying were included. We excluded papers about children, unless they reported on adult children (those aged > 18 years) or had a combined focus on adults and children

Data extraction
In line with Arksey and O'Malley's framework data extraction (charting) was multi-staged. In Stage 1 descriptive characteristics from each included paper were collected. In Stage 2 findings and discussion sections of papers were extracted into a data extraction tool. In accordance with Levac et al [32] recommendation, two reviewers independently extracted and checked data extraction.

Quality appraisal
While assessing the quality of literature included is not a requirement of scoping reviews, we undertook quality appraisal of included full text papers from peer-reviewed journals using the Critical Appraisal Skills Programme (CASP) Quality Assessment Tool -qualitative checklist [33] independently conducted by two researchers. CASP identifies 10 core questions but does not define how overall quality scores should be defined. We scored papers out of ten and expressed a percentage, those scoring ≥80% were rated as high (H), papers between 60-80% as medium (M) and those rated below ≤ 60% as low (L). (See Table 2). Quality appraisal was primarily conducted to illuminate transparency of design, aims and objectives, and sample population. However, as is standard to scoping reviews no papers were excluded on grounds of quality. Overall, we scored 29 papers as high quality, 6 medium and 3 low quality.
Mixed method papers with qualitative free text responses only, conference abstracts, dissertations and book chapters (n=13) were not assessed for quality.

Data analysis
Data extracted were treated as qualitative data and subject to thematic analysis using Braun and Clarke's approach.
[34] Themes were generated during the full text review and these were discussed within the review team and grouped together. In line with Arksey and O'Malley's framework for analysis a descriptive overview of findings, rather than a full synthesis of the evidence is provided. [31]

RESULTS
Searches identified 15,352 records. Following deduplication 8,186 records remained for assessment. After assessment, 51 papers were included in the review. Figure 2 shows the review process using the PRISMA-ScR flow diagram. [28,33] [INSERT FIGURE 2]

Characteristics of papers
Details of included papers are outlined in Table 3.    To explore lay rescuers' (bystanders) reactions, coping strategies after providing CPR to OHCA victims.

Qualitative Interviews
Lay rescuers' (bystanders) experience emotional and social challenges, concern and uncertainty after providing CPR in OHCA incidents. Common coping strategies are attempts to reduce uncertainty towards patient outcome and own CPR quality.  Interviews abuse because they value the wellbeing of the patient above their own emotional needs. Managing their own emotions as well as others is essential and achieved through compassion and professionalism -so that bystanders feel that the patient is in good hands.  about what had happened to patients after they reached the hospital emergency department were a concern. Critical incidents, such as premature deaths, [43][44][45] 54,55] and EoLC setting transitions. [55,56] Decision-making about keeping patients close to the EoL at home was complex and experiences of EoLC provision were characterised by emotional labour, [57] care crises, lack of co-ordination, a need for mediation between services [52] and gaps in communication. [50 52, 53, 58] PHPs often found it difficult to ascertain patients' EoL wishes. This was compounded by uncertainty and lack of availability of EoL advance directives and care planning, which hindered their ability to keep patients at home.[37, 50, 54, 58, 59] PHPs faced a range of system level barriers and poor EoLC co-ordination between services. [54,60] Informing families of death was also noted as an especially stressful, time-consuming and challenging task. [24] Resuscitation and OHCA were also described as particularly intense and stressful experiences, characterised by intense emotions.[48, 61-64] PHPs described complex decision-making around cardiac arrests, [65] the technical abilities required alongside providing holistic care [66] and difficult processes of negotiation with co-workers, other HCPs and families.
There was inadequate communication around Out of Hospital DNACPR orders. [65,67,68] Managing the work of death and dying PHPs used a variety of strategies to manage the work of caring for patients who died or were dying, such as collecting as much on-scene information as possible before arrival, especially when attending OHCAs. [61] This was important for understanding the context and dealing with emotional aspects. While on-scene, coping strategies such as detachment, surface acting, [35,46] humour, [35] and in the case of suicides, focusing on survivors were used.
Despite the psychological and physiological impact of caring for patients and relatives in prehospital contexts of death and dying PHPs also identified personal meaning, such as identifying with families because of their own experience of death and rewards from work in this environment[46] including a sense of pride from a job well done. [69] Perceptions on the presence of families The presence of family members and bystanders when attending death and dying calls provoked mixed reactions from PHPs, irrespective of context (e.g., OHCA, EoLC). [48,62] During OHCAs, some PHPs preferred families not to be present in the room during resuscitation and described feeling pressure from families, and expressions of disquiet related to their presence. [62] Others considered that relatives could aid resuscitation by putting on hold their own feelings and emotions, thus helping PHPs focus on the condition of the patient. [69,70] PHPs and families could provide mutual reassurance following unsuccessful resuscitations, that efforts were not inappropriate. [69] Where there were conflicts with family members, for example over resuscitation, [69] staff managed these tensions by assigning them roles in the resuscitation efforts, such as giving them a bag of fluids to hold. [ 71] The feeling that relatives were being useful could help to prevent tensions from escalating.

Training and education needs
A lack of sufficient training around communication and relational aspects of death and dying, palliative and EoLC, [24, 25,

Experiences, impact and needs of families
Few papers focussed on family and significant others' experiences but, those that did reported the lasting impact of these events. [54,60,63,70,76,77] Included papers reported on family experiences in pre-hospital palliative and EoLC, [54,60,76] OHCA, [63,70] resuscitation [69] and suicide. [77] Witnessing a family member die or dying was reported as having a significant effect on relatives and particularly at OHCAs, families experienced a range of emotions, including reactions of shock, vulnerability, responsibility and hopelessness. [63] Experiences of behaviour and communication Families described witnessing PHPs exhibiting calm and control in difficult situations, and this included interactions with parents where their adult child had died. [70] In general, family members reported experiencing mainly positive behaviours and communication with PHPs who provided competent care, [70] and in cases involving suicide showed kindness, empathy and compassion. [77] In cases where there was a death of adult children, families reported being treated with dignity by PHPs. [70] There were some reports of relatives experiencing negative interactions with PHPs, where they demonstrated a lack of awareness of family centred practice, [70] insensitivity, or little compassion in cases of suicide. [77] In such instances, families felt further training was needed.

Experiences, impact and needs of bystanders
There was a paucity of evidence around experiences and perspectives of bystanders. Papers which discussed bystander experiences, described difficulties associated with cardiac events, [78][79][80][81] including identifying OHCAs. [79] Bystanders reported a lack of knowledge around emergency services, confusion over patient symptoms requiring ambulance response at the time of cardiac events, and differing opinions on actions needed and when to call for an ambulance. [81] While the literature is limited, it appeared that irrespective of whether bystanders were passers-by or present at events, they still experienced on-going adverse reactions. These included social and psychological disturbance (e.g. guilt, self-criticism) following witnessing deaths or giving CPR and automated external defibrillation (AED) at health-educated was considered to offer some mitigation against these concerns. [78] In the UK, those working in public places and trained to use AEDs for OHCA, also reported negative consequences including flashbacks. [80] There was an identifiable need on the part of bystanders to witness visible resuscitation efforts on the part of emergency services, for feedback following sudden deaths [79] and information on patient outcomes. [78]

DISCUSSION
We conducted a scoping review to identify and explore factors that characterise and shape PHP, family, and bystander experience of death and dying in PHC and identify gaps in knowledge that warrant further research. The review identified a developing evidence base on PHPs experiences, particularly in the UK, Europe and North America. However, there were significant shortcomings in the literature in regard to the experiences, needs and impact of death and dying for families and bystanders.
Our review confirmed existing research of the varied and complex work of PHPs, [15] often requiring them to respond to a range of time critical emergencies including cardiac events,[82] placing them in situations that could be difficult to manage and which presented a range of challenges and emotional demands. This was the case for PHPs with variable expertise or length of experience and often required they utilised a variety of coping strategies. While PHPs reported feeling confident to undertake the clinical elements of managing a patient who was dying or who died, they often felt less prepared for handling the more emotional aspects particularly when it involved communicating bad news. This was also the case for providing palliative and EoLC, which is an increasing part of PHP's role, particularly in the UK, USA and Canada. In the UK, issues surrounding quality of access to EoLC services and the re-organisation of ambulance services to provide support to patients at the EoL may in part explain this growth in PHC EoLC provision.
[83] The multiple challenges that faced PHPs attending EoLC calls often meant having to utilise skills of crisis and conflict management and carry out the emotional support work of death and dying for which they reported minimal preparation or training. This places additional pressures on PHPs, already faced with complex decision making and the complexities of providing care to patients nearing the EoL, and whose actions and handling of these situation influences how people die and whether their preferences are respected. Similarly, for families, given that they may not have experienced death or dying previously, how this work is managed by PHPs is likely to influence the transition to bereavement. In the UK the key role of PHPs in the care of those at the EoL is recognised in policy, [ However, the experiences identified in this review suggest that challenges remain in the application of these recommendations and training in the real world setting of PHC.
Therefore, further research is needed to understand if, for example, these challenges are a result of stress resulting from the incident or coping mechanisms, rather than inadequate training.
While the review informed our understanding of PHPs who attended at the scene, we identified little qualitative evidence related to understanding the experience or impact of death and dying on call-handlers. This is despite them being the first point of contact and managing situations involving death and dying as an integral part to their role. The job of a call-handler is stressful and the psychological impact of dealing with emergency calls has been impact of dealing with these aspects on those undertaking this role, the challenges they face, the extent to which these are related to the nature of the role itself or organisational factors, and training and support needs. Given current concerns around the mental health of emergency service workers, and that the need for an evidence base has been highlighted recently by those who support them,[91] this is clearly an omission that merits further investigation.
Papers that included family members' accounts and experiences were few and tended to focus on their interactions with healthcare professionals, including communication and behaviours during resuscitation and cardiac events [63,69,70] EoLC, [54,60,76] the impact of cardiac events [63,70,81] and occasionally experiences of suicide. [77] Generally, relatives reported positive interactions with PHPs, commenting on their confidence and calmness in attending scenes involving death and dying, and while some families reported more negative encounters, it suggests there may be a disconnect between PHPs perceptions of the care they provide and families experience of that care. From the minority of papers identified on bystanders' experiences, there appears to be limited support available to those who have experienced stress or other symptoms from their involvement in events such as resuscitation for OHCA, or discussions about what form such support might take. Identifying and developing support mechanisms for this group will become increasingly important with the move towards encouraging bystander CPR and public access defibrillation which are key determinants in OHCA survival prior to PHP arrival. [92] A paucity of evidence relating to families and bystanders experiences and support needs is an important knowledge gap. There may be several explanations for this limited evidence base. For example, undertaking thanatological research with families and bystanders in the PHC context is likely to present both methodological and ethical challenges perceived by researchers as potential barriers to conducting research in this area. Nevertheless, as both participants in, and observers of, death and dying in the pre-hospital setting, applied research that addresses questions about experiences and impact and subsequently leads to the development of appropriate interventions is essential.

CONCLUSION
This review has shown there is a broad consistency regarding the experience of PHPs in relation to dealing with death and dying. It also identified current gaps in knowledge and areas where further empirical research that addresses specific research questions is needed. In particular, the limited evidence on call handlers suggests it is imperative to explore whether their experiences and needs are the same as those PHPs who attend at scene, or if there are differences between the two groups that need to be considered. There is also a need to investigate the effectiveness of current training in order to identify if gaps exist and the translation of this knowledge into practice and how this supports a rapidly evolving service.
The paucity of evidence on families and bystanders presents opportunities to investigate their experiences in greater depth so that we can begin to understand their needs and how these can be addressed. Future research to address the current knowledge gaps will be important for informing future policy and practice for managing death and dying in the pre-hospital context.

PATIENT AND PUBLIC INVOLVEMENT
This was a scoping review. There was no patient and public involvement at this time

STRENGTHS AND LIMITATIONS
 To our knowledge this is the first review to focus on practitioner, family and bystander experience of death and dying in pre-hospital care (PHC).
 The review will help to make better sense of pre-hospital practitioners, families and bystander experiences and to prioritise, from these perspectives, ways to improve these experiences through support and training that includes ethical issues and challenges faced by the work of death and dying  The search strategy aimed to balance sensitivity and precision, and pragmatic decisions helped achieved this balance to target studies most likely to be relevant.
However, these decisions may also have increased the risk of missing relevant records.
 A focus on healthcare systems similar to that of the United Kingdom was intended to increase transferability of findings. However, differences between these systems, and exclusion of healthcare systems that did not parallel the UK's may limit transferability. Pre-Hospital Care (PHC) is an essential part of the emergency and urgent care continuum in 3 contemporary healthcare systems across the world [1,2] and includes urgent and emergency 4 medical care that patients receive outside of the hospital setting. In the UK, PHC is provided 5 primarily by regionally based National Health Service (NHS) Ambulance Trusts and comprises 6 other services such as patient transport and NHS 111, a 24-hour online and telephone urgent 7 care service. [3] In some UK regions services are delivered by other providers, including 8 charities and private companies, but in line with NHS principles remain free at the point of 9 access, with some limited exceptions in England. For example, it is a requirement for some 10 overseas students to pay a NHS surcharge or take out private health cover. However, the 11 system in the UK is not reflected worldwide. In Australia, other than in Queensland and 12 Tasmania, ambulance services are covered either by private health insurance or are out of 13 pocket, unless an individual is eligible for a concession such as those over 65 years of age, 14 where cover is free, or in some states offered at a reduced rate. [4] Ambulance services in the 15 United States are operated by private (for-profit and non-profit) and public entities, and with 16 no free universal healthcare in the US are typically paid for by private health insurance or 17 federally funded programmes such as Medicare and Medicaid. [5] Evidence suggests the 18 nature of ambulance provision can influence the service provided. [6] 19 In the UK there is an increasing demand for PHC services. [3,4] In England for the period 2014- 20 15 the number of emergency 999 calls to ambulance switchboards totalled 9 million, a rise of 21 over 500,000 from the previous year [7] an increase mirrored in other healthcare systems.[8, 22 9] Factors contributing to increasing demand are complex and reflect the extent to which 23 work carried out in PHC has been required to react to changes in other parts of the healthcare system. [10] For example, ageing populations with complex needs, [11,12] difficulties in 25 accessing general practitioner (also known as primary care physician) services, [13] and 26 greater patient expectations and how patients seek help, [14] have meant the remit of the 27 service has changed. [15] As an evolving service pre-hospital practitioners (PHP)' work has 28 become increasingly varied and complex requiring a clinically trained workforce comprising a 29 variety of staffing combinations, such as medical dispatchers, doctors, paramedics, 30 emergency medical technicians, and emergency care practitioners. 31 The As first responders to crises that immediately precede death, confronting death and dying is 44 an intrinsic part of the work of PHPs. [21] When providing care to someone who is dying, or 45 dies, they are often required to make challenging decisions and deal with the clinical and 46 emotional aspects of a situation simultaneously. [22] This requires management of their own qualified PHPs to confirm death and cease resuscitation in the field. [23] Similarly, in the USA 51 and Canada paramedics can confirm death on-scene. [24,25] This aspect of their work has the 52 accompanying responsibility of informing relatives or others present that the patient has died. 53 The provision of care to someone who is dying, and their relatives, has been identified as one 54 of the most stressful human experiences [22,26] and acknowledged as challenging for 55 healthcare professionals generally. [27,28] For those working in PHC, this may be more 56 complex partly because ambulance crews are immediately required to assess and respond to 57 a situation, [26] and the transient nature of the job may not present opportunities to establish 58 rapport with a dying patient or their relatives, which may have a lasting impact for survivor 59 families into bereavement. In dealing with death and dying PHPs engage in 'moral work' 60 needed to navigate the difficult ethical challenges they experience in this particular context. 61 These include managing expectations from families and providing patient-centred care that 62 is in the best interests of the patient. The recent global COVID-19 pandemic has posed 63 additional ethical demands on PHPs. [29] In particular, decision-making may be influenced by 64 the rationing of scarce resources, being unable to provide the level of individual care to 65 patients and families they would under more usual conditions, not being deployed to patients 66 they would have attended previously, and leaving patients at home who otherwise would 67 have been transferred. [30,31] Such ethical challenges may lead to increasing levels of moral 68 distress [32,33] for PHPs who are unable to pursue what they consider to be the right course 69 of action due to varying internal and/or external constraints. To date, little is known about the effects on families and others present, or support 71 mechanisms in place for relatives or bystanders who witness an incident when a patient dies 72 where PHPs attend. Similarly, while we know that PHPs encounter death and dying routinely 73 in the course of their work, we understand less about the nature of this aspect of their job, 74 the impact of dealing with death and dying, how they manage situations where a patient dies 75 especially when they do not always have opportunities to debrief with their colleagues,[34] 76 or their emotional, psychological, educational and training needs in relation to death and 77 dying. 78 This review is needed to better inform our understanding about the experiences and needs 79 of PHPs, families and bystanders in the pre-hospital context of death and dying in order to 80 identify areas for further research. 81 Aim of the review 82 In this paper we present a scoping review that explores evidence guided by the question: 83 What is known about the factors that shape and characterise experiences of PHPs, families,   124 Papers were selected using specific eligibility criteria outlined in Table 2 1  2  3  4  5  6  7  8  9  10  11  12  13  14  15  16  17  18  19  20  21  22  23  24  25  26  27  28  29  30  31  32  33  34  35  36  37  38  39  40  41  42  43  44  45  To explore lay rescuers' (bystanders) reactions, coping strategies after providing CPR to OHCA victims.

Qualitative Interviews
Lay rescuers' (bystanders) experience emotional and social challenges, concern and uncertainty after providing CPR in OHCA incidents. Common coping strategies are attempts to reduce uncertainty towards patient outcome and own CPR quality. To explore paramedic decisionmaking when transporting nursing home residents nearing EOL.

Qualitative Interviews
Paramedics identified difficulties in understanding nursing home residents' wishes. Used best interest decision-making, weighing the risks and benefits of hospitalisation. Decision making became a process of negotiation when the patient's perceived best interests conflicted with that of others, resulting in contrasting approaches by paramedics.

Pre-Hospital Providers
To explore pre-hospital providers decision making when encountering imminent death from serious illness.

Pre-Hospital Providers
To explore and describe prehospital providers' assessments and management of EOL emergency calls.

Qualitative Interviews
The importance of managing symptom crises and stress responses that accompany the dying process is essential to quality care at EoL including managing the emotionality of the event and supporting families.

Qualitative Interviews
Themes identified were the challenge of identifying OHCA, collaboration with the medical dispatcher and the ambulance crew, coping with the experience of sudden death, reflections on what more could have been done and experience for the future, the outcome of the patient and the perceptual experience with OHCA. To explore professionals' experiences on the implementation of advance care planning in two areas of clinical care, dementia and palliative care.

Qualitative Focus Groups Interviews
There was uncertainty over the general value of advance care planning, whether current service provision could meet patient wishes, their individual roles and responsibilities and which aspects of advance care planning were legally binding; the array of different advance care planning forms and documentation available added to the confusion 10 (100%)-H

Williams 2013
Journal Paper UK Paramedic students

Pre-registration Paramedic Science Students
To explore student paramedic perceptions and experiences of emotion work and the strategies used to deal with it.

Qualitative Interviews
The findings reveal evidence of emotion work in emergency situations where there is a need to control and suppress emotions to do the job, struggling with emotion and a need for talking it through. To explore paramedics' experiences and coping strategies with death notification in the field.

389
Search is restricted to the publication type field or/1-29 Combines sets 1 to 29 using OR   Provide a structured summary that includes (as applicable): background, objectives, eligibility criteria, sources of evidence, charting methods, results, and conclusions that relate to the review questions and objectives.

Rationale 3
Describe the rationale for the review in the context of what is already known. Explain why the review questions/objectives lend themselves to a scoping review approach.

4-7
Objectives 4 Provide an explicit statement of the questions and objectives being addressed with reference to their key elements (e.g., population or participants, concepts, and context) or other relevant key elements used to conceptualize the review questions and/or objectives.

Protocol and registration 5
Indicate whether a review protocol exists; state if and where it can be accessed (e.g., a Web address); and if available, provide registration information, including the registration number.
A protocol exists but has not been published.

Eligibility criteria 6
Specify characteristics of the sources of evidence used as eligibility criteria (e.g., years considered, language, and publication status), and provide a rationale.

9-10
Information sources* 7 Describe all information sources in the search (e.g., databases with dates of coverage and contact with authors to identify additional sources), as well as the date the most recent search was executed.

8-9
Search 8 Present the full electronic search strategy for at least 1 database, including any limits used, such that it could be repeated. 9 + Figure 1 Selection of sources of evidence † 9 State the process for selecting sources of evidence (i.e., screening and eligibility) included in the scoping review.
10 Data charting process ‡ 10 Describe the methods of charting data from the included sources of evidence (e.g., calibrated forms or forms that have been tested by the team before their use, and whether data charting was done independently or in duplicate) and any processes for obtaining and confirming data from investigators.

10-11
Data items 11 List and define all variables for which data were sought and any assumptions and simplifications made. If done, provide a rationale for conducting a critical appraisal of included sources of evidence; describe the methods used and how this information was used in any data synthesis (if appropriate).

11
Synthesis of results 13 Describe the methods of handling and summarizing the data that were charted. 11-12

Selection of sources of evidence 14
Give numbers of sources of evidence screened, assessed for eligibility, and included in the review, with reasons for exclusions at each stage, ideally using a flow diagram.
12 + Figure 2 Characteristics of sources of evidence 15 For each source of evidence, present characteristics for which data were charted and provide the citations.
12 + Table 3 Critical appraisal within sources of evidence 16 If done, present data on critical appraisal of included sources of evidence (see item 12). 11 + Table 3 Results of individual sources of evidence

17
For each included source of evidence, present the relevant data that were charted that relate to the review questions and objectives.

14-27
Synthesis of results 18 Summarize and/or present the charting results as they relate to the review questions and objectives. 28-33

Summary of evidence 19
Summarize the main results (including an overview of concepts, themes, and types of evidence available), link to the review questions and objectives, and consider the relevance to key groups.

33-36
Limitations 20 Discuss the limitations of the scoping review process. 3

Conclusions 21
Provide a general interpretation of the results with respect to the review questions and objectives, as well as potential implications and/or next steps.

Funding 22
Describe sources of funding for the included sources of evidence, as well as sources of funding for the scoping review. Describe the role of the funders of the scoping review. 37 JBI = Joanna Briggs Institute; PRISMA-ScR = Preferred Reporting Items for Systematic reviews and Meta-Analyses extension for Scoping Reviews. * Where sources of evidence (see second footnote) are compiled from, such as bibliographic databases, social media platforms, and Web sites. † A more inclusive/heterogeneous term used to account for the different types of evidence or data sources (e.g., quantitative and/or qualitative research, expert opinion, and policy documents) that may be eligible in a scoping review as opposed to only studies. This is not to be confused with information sources (see first footnote). ‡ The frameworks by Arksey and O'Malley (6) and Levac and colleagues (7) and the JBI guidance (4,5) refer to the process of data extraction in a scoping review as data charting. § The process of systematically examining research evidence to assess its validity, results, and relevance before using it to inform a decision. This term is used for items 12 and 19 instead of "risk of bias" (which is more applicable to systematic reviews of interventions) to include and acknowledge the various sources of evidence that may be used in a scoping review (e.g., quantitative and/or qualitative research, expert opinion, and policy document).  1  2  3  4  5  6  7  8  9  10  11  12  13  14  15  16  17  18  19  20  21  22  23  24  25  26  27  28  29  30  31  32  33  34  35  36  37  38  39  40  41  42  43  44  45  46  47  48  49  50  51  52  53  54  55  56  57  58  59  60