Palliative Medication Administration

Paramedics are permitted to administer hydromorphone (ACP only) and haloperidol (ACP and PCP) under the following conditions:

1. The patient is registered in a palliative care program.
2. This program does not need to be registered with the Paramedic Service or CACC
3. It must be an actual palliative program and not just a part of a general home nursing or community paramedic program
4. The ACR should include that the patient is part of a registered palliative program and that notes were made in the palliative file or palliative team contacted

1. For patients not registered in a palliative care program, a patch to a BHP is required for orders.

Note: Paramedics may apply the treat-and-refer part of the palliative directive to any palliative patient who has a care team that can follow-up, and is not restricted to those registered in a palliative program.

Rationale
Administration of hydromorphone and haloperidol are controlled medical acts, and thus paramedics are only permitted to administer them as prescribed by Medical Directives or if given a BHP order. As these hydromorphone and haloperidol are only contained in the Special Project Palliative Care Medical Directive, they can only legally be administered under this directive.

Special Project Palliative Care Medical Directive

• The sections for Pain or Dyspnea, Hallucinations or Agitation, and Nausea or Vomiting, include hydromorphone and haloperidol administration.
• Indications for these medications include the wording Patient registered in palliative care program along with the clinical presentation.

RPPEO's Teaching
In Fall 2025 CME Associate Medical Director Dr Mark Froats provided this guidance, excerpts from

https://mediclearn.rppeo.ca/mod/url/view.php?id=12384

• The palliative care model for paramedics applies to any patient with a life limiting illness who prefers to remain at home. You can apply the palliative pathway even when no immediate treatment or medication is required
• When this model of care was first introduced, patients needed to be enrolled in a palliative care program and have an official palliative care team. This was to ensure there was follow-up care in place for those being treated at home. Enrollment is no longer a requirement. What's crucial is that the patient has access to a care team. This could be a palliative care team, a family physician, nurse practitioner, or community paramedics who can follow-up with the patient's needs. If a care team is in place, the patient consents to follow-up, and managing their life limiting illness at home is feasible, they qualify for treat and refer under this model.
• A patch is not required to administer palliative medications or provide treatment refer under the palliative model as long as treatment aligns with the directives.

RPPEO's Position

• Excerpt 3 confirms that a patch is not required if the patient the aligns with the directives, this means that the patient must meet the indications and conditions, and not have any contraindications.
• As the palliative care directive includes the indication that the patient is registered in palliative care program, this is a legal requirement to perform a controlled medical act.
• Excerpt 2 is referring to patients being left at home under the treat-and-refer section; this can be applied more broadly as it is not a controlled medical act.

Note: the ALS PCS are undergoing a major review and it is anticipated that hydromorphone and haloperidol will be included in the ALS PCS, allowing greater scope for paramedics to use these medications in patient care without patching for orders.