Background Responding to the needs of patients at end-of-life can present challenges for the ambulance service. Facing increasing demand, complexity of patient care needs and a desire to avoid unnecessary transfers to the emergency department, local ambulance services have developed initiatives to help improve the care provided to this patient group.

We undertook a systematic review to determine what initiatives are being used to improve end-of-life care delivered by ambulance services, their characteristics, effectiveness and how they might work. We also sought to understand the experiences of patients and ambulance staff.

Methods We searched MEDLINE, CINAHL, ASSIA, Embase and grey literature sources to identify English language articles published in the last 10 years that describe initiatives to improve the provision of end-of-life care by ambulance services. We used a PICO framework and a customised data extraction form and undertook a narrative synthesis.

Results We reviewed 4,276 records and included 58 in the final review.

We identified eleven different types of initiative then developed a 3 domain framework based on their characteristics to describe the underlying theory of how they worked;

1. Aiding decision making process

2. Providing most effective therapies

3. Providing most appropriate response

Only eight studies contained evidence of initiative effectiveness;

• 5 showed improved staff confidence

• 3 showed improved patient outcomes

Four studies investigated the experiences of those impacted by the initiatives, only two of which included the patient voice. In these, patients were broadly positive about the initiatives and the care they had received.

Conclusion Numerous initiatives have been developed to improve pre-hospital end-of-life care delivered by ambulance services, however evidence to show their impact on patient outcomes is limited. Further research to understand patient experiences of care provided by the ambulance service would be beneficial to inform the ongoing development of initiatives in the future.