The pre-hospital emergency service deals directly with saving lives and, therefore, faces ethical conflicts in decision making involving patients at risk of death. The distance from places with more resources, the provision of care at the patient’s residence, the realization of procedures on public roads, and a low number of team members contribute to make the work stressful and challenging. The work of these professionals with PC patients is even more challenging and conflicting because it involves conflicts related to futile therapies that prolong suffering.
The nuclei of meaning Death as taboo and Professional training emerging from the theme ‘unpreparedness’ represent the perceptions of the PHC professionals regarding the team’s inability to deal with death and care in the case of PC patients, which is reflected in the outcomes of care. Professionals identify death as a professional failure and understand that the role of the PHC service is to save lives, justifying the adoption of extraordinary procedures in the care of patients in PC.
Death is defined as a taboo to be deconstructed by all professional categories, because they understand death as a professional failure and not as an episode, that is part of life. Professionals often run away from terminal patients, do not talk about it, masking death .
Other authors  made an analysis of the professionals’ performance in face of their worldviews, considering the biomedical vision, where patients are seen as mere carriers of diseases and that the professional must be able to treat and cure at all costs and the holistic vision considering the integrality and factors that permeate health as the social and psychological. For professionals immersed in a biomedical vision, death is considered a professional failure that should be avoided at all costs.
Death anxiety has a high prevalence in some professional categories, among them the emergency medical team, due to occupational exposure to injured patients, as well as terminal patients, it can be seen through studies that found that the older the ES professional is, the lower his level and anxiety for death . Other studies concluded that ES teams who reported personal experiences ‘resolved’ with grief were more comfortable with the end of resuscitation and patient death .
As understood by the participants in this study, professional training and continuing education need to address the issue of death, as observed in a study conducted in Canada. A research  analyzed the barriers for the implementation of PC in Canada in relation to four countries (United Kingdom, Ireland, New Zealand and Australia) and the results emphasized that significant investments in undergraduate and graduate courses in medicine and nursing are necessary to train professionals in PC, with knowledge and skills to meet the fundamental needs of this profile of patient. However, professionals who are already in the work market need continuing education to meet such demands.
It is a fact that it is necessary to reformulate the curricula in the training of health professionals, since there is a lack of disciplines involving the theme of death and palliative care, contributing to the debate on the subject and promoting greater security to the professional when faced with the issue of death .
The decision to suspend or terminate resuscitation is not easy and results suggest that the ES team, feel insufficiently prepared to communicate the death, as well as do not know how to deal with the anguish of the families, the researches point out the need for greater Interventions in professional training for the notification of death, emergency care, decision making of resuscitation and death of the patient, in order to better prepare the ES teams to deal with the various situations [30, 31]. One fact is that without adequate preparation and support, it seems that the team distances itself from good decision making in order to avoid the management of patient death and later involvement with family pain. Feeling unprepared and unsupported has been associated with increased anguish and anxiety regarding the death of health professionals [32, 33].
According to another study , members of the emergency team chose biomedical studies as more important when compared to the psychological and social approach. That said, the offer of additional training and continuing education aimed at death has an impact, favoring more reliable and assertive decisions, especially when associated with complex issues which are not part of the routine of professionals who deal with acute events.
The challenge for public policy managers, with the increase in demand for the care of PC by generalist professionals, leads one to think about what skills are needed to care for patients and their families. Communication skills, empathy, analysis of needs and preferences, anticipated care planning are required. These skills should be included in the curriculum of undergraduate and graduate health professionals. Even in the face of this insertion, there is no instrument that can be used to evaluate this competence in palliative care, because it is quite complex .
The theme ‘Decision making’ reflects ethical conflicts and their impact on care outcomes related to limited or even nonexistent information on the patient’s current health condition and the family approach at the moment of the occurrence.
The results of a qualitative research  revealed that professionals working in the pre-hospital service were concerned with the patient’s manifestations of will, but there was a possibility of contradicting the objectives of the service they perform. They also expressed a feeling of helplessness regarding the will of the family in relation to the NRO, and confessed that there was distrust in accepting the manifestations contained in the document even seeing the signature of the patient’s physician.
In order to assess the care provided to terminally ill patients in their homes, researchers  conducted a qualitative investigation in an English hospital and the results demonstrated that a set of factors impaired the ability of respondents to keep patients at their homes when they were close to the end of life. Such factors were: poor availability of support in the community, limited information about the patient and his health condition, and tendency towards invasive procedures in PHC.
The results found in the present study are consistent with the findings presented in that research. There is a need for quick decision making in PHC and the limitation of information about the patients’ history and care preferences often interferes with their permanence in their residence, leading to successive hospitalizations and the performance of futile procedures .
A systematic literature review  showed that in countries such as Australia, New Zealand, Canada and countries of Europe, where medical records of patients are shared by the health systems, the choice of actions and care measures in during emergency calls are facilitated. The study also emphasized that when the information is integrated between primary care and specialized PC services, positive factors are observed in terms of less repeated admissions and shortest hospital stay, besides relevant improvements in pain control and other symptoms and, consequently, improved Quality of Life (QOL) for patients.
The importance of a professional culture focused on Anticipated Care Planning, as a process of discussion and registration of patients’ preferences for future care and health decisions about the end of life, is also highlighted. A qualitative study conducted with health professionals from seven hospital PC teams in Brazil identified the need to approach the ADWs with the patient, emphasizing the importance of establishing bonds of trust with the patient, effective communication with the patient and the approach in the family context .
Thus, the lack of information on the current health status of the patient and the approach of the family at the time of the occurrence reflects the lack of a prior approach to ARVs with the patient and family, in addition to the lack of integration and communication between health services and professionals with the emergency and emergency services, as identified in the results of this study.
In addition, it becomes relevant to adopt an emergency care plan that allows doctors to discuss and record patient preferences in advance, not only in relation to CPR, but all aspects of care and treatment in an emergency, providing recommendations for care and treatment for future scenarios. A systematic review study has identified that these plans should be considered when attending people with complex health needs, limiting living conditions, or diseases that predispose to sudden deterioration or cardiac arrest. And that some triggers may indicate the need to initiate a discussion on emergency care plans, such as: requests from the patient himself; recognition of complex or long-term medical needs during care in clinics and wards of hospitals, as well as in general practice; diagnosis of a life-limiting condition – recognition that care at the end of life will be necessary; admission to a nursing home and identified risk of acute deterioration, cardiac arrest, or death .
The theme ‘dysthanasia’, which addressed the issue of carrying out futile procedures and referrals to hospital admissions, demonstrated the concern of professionals working in the emergency service with the actions adopted in the pre-hospital service in the country side of Brazil.
Despite this, the results of a study  demonstrated that it was more acceptable for the emergency team to start treatment and then leave it if the expected benefit was not obtained than “doing absolutely nothing” (p. 41). Death can be seen as a failure in the care provided and many professionals do not notice the value of choices and end-of-life desires, such as dying at home and in the presence of relatives .
It was observed in this study that, although the professionals understand that PC should be taken into account in cases assisted by the PHC, the lack of knowledge of family members and lack of integration between health services result in the implementation of futile therapies, which will only prolong the suffering of patients and families.
In this context, the curative medical model contributes considerably to disease-centered approaches, leading to the adoption of futile procedures for prolonging life, and a discouraging understanding about communication in terminal care between members of the multidisciplinary team, patients and family members. However, this culture can be modified directly through education and training, and can be also influenced by the success of previous cases, because positive experiences and results drive the team’s reasoning and encourage the continuous practice of actions .
Decisions involving whether or not to transport the patient to specialized services also generate conflicts within the PHC team, because keeping the patient at home involves decisions that go beyond clinical knowledge, and the rate of future calls for the emergency service is high when the patient remains at home .
In this context, Home Care (HC) is a type of assistance favorable to PC, since the philosophy and principles that guide PC and HC are similar. However, it is known that the curative, technical and biological aspects of care present in the health system offered in Brazil do not favor the implementation of these principles in the context of HC .
Other studies [43,44,45], indicate that, sometimes, the feeling of uncertainty and the fear of lawsuits come from limited and unreliable information regarding end-of-life patients. Thus, even when the team knows that transportation to the hospital will not benefit the patient’s current health condition, the professionals think that the stay in the home is not safe and end up making a decision that is often inappropriate or even contrary to the patient’s will.
Thus, if PHC professionals had information and established effective communication with other services, there would be discussions for better decisions about transportation, actions performed, and acceptance of the patient’s desires. In this context, the role of nurses in PHC stands out because they constitute the main link among professionals of the team and they have the ability to communicate effectively with patients and their families.
The limitations of this study include the small number of participants and the realization in the context of a single municipality; however, it is understood that the results of this research reflect the reality of PHC in Brazil.
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