Background In Germany, paramedics and emergency physicians arrive separately on scene ("rendez-vous-system"), which aims to save resources when no physician is needed. Usually, paramedics arrive firstly on scene, and are obliged by law to perform all possible action to maintain a patient's life. Especially in end-of-life (EoL) situations, this can cause conflicts, as those patients may require a decent consideration between "saving life" and "allowing to die". Whereas the emergency physicians' perspective on this issue is relatively well examined, until today, in Germany, little is known about the (non-physician) paramedics' perception. Aim To explore paramedics' perception of rescue scenarios involving patients with advanced, incurable, severe diseases facing their EoL and to scientifically classify this cross-sectional field through experts from different research fields. Method Seven semi-structured narrative interviews with paramedics and one focus group with representatives from the Center for Medical Law in Goettingen were conducted and analysed using qualitative content analysis. Results Six key categories emerged from the data. Rescue scenarios in EoL situations are perceived as highly complex situations that are narrowed down through deviating goals of care (1), limited options for action (2), an emotional overload of all involved actors (3), consequences of a neglected (care) planning in advance (4) and various background structures, such as current societal and demographic changes (5) and systemic challenges (6). Complexity also arises from the multiple influences of the different categories/ their content on one another. Discussion Being confronted with patients that do not wish for further life-maintaining treatment marks a significant shift concerning the range of rescue scenarios, resulting from (i.a.) demographic developments and structural dynamics in health care. Therefore, in addition to specific actions restoring paramedics' ability to act in rescue scenarios in EoL situations, a general discussion of the emergency services' area of responsibility as well as the (emergency) medical treatment and care of patients with advanced, incurable, severe diseases is required.

The authors have declared no competing interest.

NO - The authors received no specific funding for this work.

I confirm all relevant ethical guidelines have been followed, and any necessary IRB and/or ethics committee approvals have been obtained.

Yes

The details of the IRB/oversight body that provided approval or exemption for the research described are given below:

The study received approval from the Research Ethics Committee of the University Medical Center Goettingen (21/10/19).

I confirm that all necessary patient/participant consent has been obtained and the appropriate institutional forms have been archived, and that any patient/participant/sample identifiers included were not known to anyone (e.g., hospital staff, patients or participants themselves) outside the research group so cannot be used to identify individuals.

Yes

I understand that all clinical trials and any other prospective interventional studies must be registered with an ICMJE-approved registry, such as ClinicalTrials.gov. I confirm that any such study reported in the manuscript has been registered and the trial registration ID is provided (note: if posting a prospective study registered retrospectively, please provide a statement in the trial ID field explaining why the study was not registered in advance).

Yes

I have followed all appropriate research reporting guidelines and uploaded the relevant EQUATOR Network research reporting checklist(s) and other pertinent material as supplementary files, if applicable.

Yes

Data cannot be shared publicly because of limited anonymity. Data are available from the Department for Palliative Medicine at the University Medical Center Goettingen (contact via pallia-tiv.forschung@med.uni-goettingen.de) for researchers who meet the criteria for access to confidential data.