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5 steps to address physical and cognitive issues in an aging EMS workforce

If an EMS provider’s diminished capacity prevents them from performing the job’s essential functions or puts anyone’s safety at risk, consider reasonable accommodations


Physical and cognitive decline affects us all, but may impact our older caregivers in more pronounced ways. EMS leaders need to balance safety, dignity and confusing legal parameters in dealing with this issue.

AP Photo/Chris Post

By Jay Fitch, PhD

There is overwhelming anecdotal evidence but little published data indicating that older EMS practitioners struggle to perform their duties. Physical and cognitive decline affects us all, but may impact our older caregivers in more pronounced ways. EMS leaders need to balance safety, dignity and confusing legal parameters in dealing with this issue. At the end of this article, find a quick-reference resource you can download and keep in your files to reference when addressing a provider’s cognitive or mental decline.

The physical side of the equation is usually easier to observe and diagnose than losses in cognitive function. When caregivers have difficulty lifting a stretcher, climbing stairs or performing an extrication, the impacts of aging become readily apparent. However, when cognitive impairment occurs, it may be much more subtle.

Common signs of cognitive impairment include forgetfulness and taking more time to process information. Over time, if cognitive changes deepen, managers and coworkers may notice a measurable decline in memory, language and critical thinking ability. Underlying health conditions, including poor nutrition, sleep disorders or depression may also be contributing factors.

One of the older medics I recently interviewed said, “it’s like my mind is stuck in low gear while the younger medics smoothly accelerate and shift into high.” He went on to say, “I eventually figure out what’s (clinically) going on, but I’m not as quick as I used to be and that frustrates the snot out of me.”

Assess caregivers for diminished capacity

What’s an EMS Leader to do? We operate in an environment that demands leaders quickly assess if a caregiver’s diminished capacity could result in harm to themselves or others. Having clear policies in place that address physical and cognitive impairment is a good first step. Other recommendations include:

  1. Conduct a safety assessment. If there is reasonable belief that the caregiver’s condition may prevent them from performing the job’s essential functions, or that the caregiver poses a direct threat to his/her own safety or the safety of others, then consider ordering a fit-for-duty exam. A fit-for-duty exam is a medical examination of a current employee to determine whether the employee is physically or psychologically able to perform the job. The supervisor’s decision to request the exam must be based on facts, not on stereotypes or assumptions about the employee’s condition.
  2. Engage the caregiver. It’s a manager’s responsibility to engage the caregiver to fully understand specific performance issues. The caregiver may have recognized the changes in their own abilities before you have. A conversation about performance is an opportunity to express supportive concern and factually describe the negative impact of the caregiver’s poor performance on patients and the organization. Avoid making any judgmental statements, or age-related or disability-related comments.
  3. Keep thorough records. As in all things associated with personnel matters, having solid, appropriate documentation is important. Maintaining records that document the caregiver’s performance issues, your discussions and the rationale for any decisions are critical if your subsequent actions are questioned, challenged or even result in litigation.
  4. Consider reasonable accommodations. Agencies considering whether they can provide reasonable accommodations should ask these questions: How do the caregiver’s limitations affect job performance? What specific tasks are problematic? Are there accommodations available to reduce or eliminate those problems? Has the caregiver been asked what accommodations he or she believes may help? For example, it may be a reasonable accommodation if a caregiver has a physical limitation related to lifting to offer a position in communications (assuming they are or can become qualified as an emergency medical dispatcher). However, should that same individual have cognitive limitations, offering a position in communications would not be a reasonable accommodation as the communications position also requires high cognitive capabilities.
  5. Termination may be necessary if other options fail. There are some situations in which the person can no longer perform essential functions and reasonable accommodations don’t help. Sadly, managers and human resource leaders have no choice but to terminate the caregiver in accordance with the organization’s policies and the Americans with Disabilities Act (ADA) guidelines.

A case study in modifying an aging EMS provider’s role

Hal is a clear illustration of how difficult these situations can be for both caregivers and EMS leaders. Hal is a 56-year-old medic who works in a suburban EMS system that staffs its units with one medic and one EMT. His partners complained that he is increasingly forgetful and “is not as sharp as normal” when assessing and caring for patients.

After several complaints, the manager engaged Hal in a conversation about his performance. During that conversation, Hal volunteered that, “I’m increasingly having trouble keeping it together in the field. I’m constantly tired, don’t have any energy and I’m having trouble thinking as fast as I used to.” He went on to say, “I’ve worked here almost my whole career. You and I were great partners before you got promoted. Can’t you cut me some slack?”

Under the provisions of the ADA, the agency tried to determine what help Hal needed to do the job without creating an undue burden on the organization. In Hal’s case, his manager considered offering him placement on a shorter shift to help him cope with fatigue issues. Hal also requested that he always be assigned with another paramedic. Is Hal’s request a reasonable accommodation that the service should make?

The agency decided that assigning another medic to work with Hal was not a reasonable accommodation because it placed an undue financial hardship on the agency. A fit-for-duty exam conducted by an independent examiner in accordance with the agency’s policies documented that Hal indeed had mild cognitive impairment.

Hal was subsequently offered and accepted a position in the service’s logistics department. The compensation for the logistics position is at a lower rate of pay than he earned as a medic. Hal continues to function well in that role with the aid of a daily checklist he can check off as he completes specific tasks.

Treating aging EMS providers with dignity

EMS organizations are learning to navigate delicate conversations with aging workers and volunteers that are grappling with physical limitations and cognitive declines. Treating caregivers with dignity, not violating the ADA’s regulatory requirements and always thinking about the implications for the patients we serve is indeed a difficult task.

About the author

Jay Fitch, PhD, is the founding partner of EMS/public safety consulting firm Fitch & Associates. He also serves as a commissioner for the American College of Paramedic Executives. Contact him directly at

For more than three decades, the Fitch & Associates team of consultants has provided customized solutions to the complex challenges faced by public safety organizations of all types and sizes. From system design and competitive procurements to technology upgrades and comprehensive consulting services, Fitch & Associates helps communities ensure their emergency services are both effective and sustainable. For ideas to help your agency improve performance in the face of rising costs, call 888-431-2600 or visit