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Anticipatory prescribing in palliative care

Anticipatory prescribing ( AP ) is the prescribing of injectable medications in advance of clinical need, for visiting nurses or doctors to give as required if symptoms arise in the final days of life ( BMJ 2021 )

 

Research has shown that up to 90 % of people with life threatening illness would like to die at home or in a home like environment The number of people dying outside the hospital environment ( for e.g care homes , homes ) has risen sharply across the globe in recent yrs This practice of anticipatory prescribing ( AP ) is quite common in the UK ,New Zealand and Australia and less commonly in the USA , Singapore and Norway Timely access to medications is critical as symptoms in people with advance illness can change rapidly due to sudden deterioration , exacerbations of existing symptoms , poor absorption or the fact that oral administration of drugs is no longer possible Delay in waiting to see an OOH doctor- then to arrange medications via a chemist can be distressing for both the patients and the family Anticipatory prescribing tries to address the major symptom complex that patients may face entering the terminal phase of life as pain , agitation , nausea and vomiting , breathlessness and excessive chest secretions These medications are issued in anticipation that the patient entering the last few hours of life would be unable to swallow their regular medications and use of these via S/C route would help alleviate the symptoms Anticipatory prescribing can be considered as part of advanced care planning.

 

primary care has a key role in providing palliative care to patients nearing the end of their life – and in decisions about prescribing anticipatory medications A BJGP article has concluded that GPs view AP as a key to symptom management for patients at the end of life Once issued GPs are accountable for the medications and they are administered by the nurses based on their clinical assessment that the person is dying or has distressing symptoms Controlled drugs can be left in the community for long periods of time & the drugs can be open to misuse if there is a history of drug abuse in the home or they are given in inappropriate doses by the visiting clinician Hence doctors have very little control over what happens when the drug is actually administered It has not been investigated what information GPs discuss with patients and families about anticipatory prescribing

 

all adult patients with a terminal illness are eligible patient considered to be in the last few weeks of life palliative care register district nurses, hospice nurses – have informed that the patient may need AP palliative care team in community hospital discharge DS1500 form has been issued it is anticipated that the patients medical condition may deteriorate into terminal phase of illness within 2 -3 months

 

the healthcare professional authorising the administration of AP -accepts responsibility for that decision the prescriber should be satisfied that the patients and carers understand the reasons for the medications , discuss the prognosis & ensure they understand how to access care if their health deteriorates the availability of the medication at patients home is in no way a substitute for proper clinical evaluation at the time of a change in the patients condition list of medication in AP should be agreed locally with input from for e.g LMC , other lead GP’s , local hospice , McMillian teams prescribing should be tailored individually to the patients underlying needs ie same medications should not be issued to all printable sheets with normal starting doses should be agreed and available to minimise prescribing errors consider supply / waste aspect to determine quantity of supply the JIC box should have atleast – the anticipated drugs , administration equipment , written instructions – dose and indications and a way to keep a record other stakeholders as OOH & all others involved in the patients care must be informed of the clinical situation and availability of drugs

 

Gain permission from the patient – if they lack capacity it is acceptable to obtain permission of the patients family or carers Normally 5-10 ampoules of each medicine is issued ( based on local guidance ) Just in case box ( JIC ) and Targeted Anticipatory Prescribing are the two terms used in AP JIC – is a box that is placed in the patient’s home , containing medications and sundries that may be required to help symptoms towards the end of life JIC box is sealed and remains unopened until needed

 

diamorphine fentanyl for e.g in renal failure Oxycodone Alfentanil ( drug of choice in patients with renal disease )

 

the doses / agents may vary based on circumstances if the patient is already on significant doses of opioids – the equivalent of current oral when required opioid dose should be prescribed for patient who are opiate naive the lowest effective dose ( often 2.5 mg ) should be considered the JIC is not for patients in of urgent / immediate need of medications as it may take up to 72 hrs to arrange the JIC box For patients on opioid patches a prescription should include a strong opiate to cover the need for PRN or increase in analgesia In case you have concerns about issuing controlled drugs with a vulnerable patient you may consider contacting the CDLO – controlled drug liaison officer via www.apcdlo.org ( in England )

 

Issue an FP -10 and mention JIC box – Please supply as a Just in case pack -pharmacy will treat that as urgent

It is always easier to use the practice system for e.g Vision / EMIS as it documents the dose / quantity and less likelihood of prescribing errors ( given that this does not contribute to a significant delay ) & some systems may have protocols built in to issue emergency box & will generate the necessary prescriptions

 

Document all the discussion consent / names / details / doses in the patients medical records

 

Complete a community prescription chart – as required medications / anticipatory with clear instructions of use as the named of medicine / dose/ route / frequency / indication -sign and date each entry – this would be added in the JIC box 
( check local guidance )

Consider a discussion about DBACPR where appropriate

 

Ensure that the patient is added to the palliative care register of the practice if not done already

 

a syringe pump prescription is not recommended at this stage also check the local policy if it is permitted agreed to issue JIC box for nursing home residents – in that case prescribe as normal some care homes with without nursing support may also be unsuitable for JIC as prescribed should check that the patient / carers know who to contact should any symptoms problems occur hand over a JIC box leaflet -please look at the link section inform the district nurses service and OOH that AP has been issued – some areas may have the facility to do this digitally if the contents of the JIC box are not required any more they should be returned to the issuing / or any other pharmacy

 

The community nurses take an empty JIC box / bag , add the required sundries and place it it the patients home – medications are then addedThe JIC remains at home unopened until needed when the healthcare professional ( e.g nurse , doctor , paramedic ) will break the seal

 

The supply from JIC may only last 24 hrs or a little more based on the need – ensure further supply of drugs for continuing need following a reassessment. 
Based on local policy a SD may be indicated for e.g if 3 or more doses of the prescribed medications are administered within 24 hrs

REFERENCES

  1. Anticipatory prescribing for end-of-life care BMA Anticipatory prescribing for end-of-life care (bma.org.uk)
  2. The gold standards framework – Examples of Good Practice Resource Guide Just in Case Box 2006 Microsoft Word – Examples of Good Practice Resource Guide Just in Case Boxe… (goldstandardsframework.org.uk)
  3. Scottish Palliative Care Guidelines Anticipatory Prescribing Scottish Palliative Care Guidelines – Anticipatory Prescribing
  4. GPs’ decisions about prescribing end-of-life anticipatory medications: a qualitative study
    Ben BowersSam S BarclayKristian PollockStephen Barclay
  5. Policy for Anticipatory Prescribing and Supply of Palliative Care Medications for Adults *P_CS_18_Policy_for_Anticipatory_Prescribing_and_Supply_of_Palliatve_Care_Medications_for_Adults.pdf (lincolnshirecommunityhealthservices.nhs.uk)
  6. Anticipatory Prescribing in Palliative care – Access to Medication in the community Anticipatory Prescribing July 2018.pdf (pallcare.info)
  7. NHS Forth Valley Guideline for the use of Just in Case Boxes in the Community *Process for the Development and Implementation of (nhsforthvalley.com)
  8. Shropshire Clinical Commissioning Group Palliative Care Just in Case Service Guidance Just-in-Case-pack-Service-Guidance.pdf (severnhospice.org.uk)
  9. Anticipatory prescribing for dying patients – A pilot study of Just in Case Boxes in NHS Lanarkshire 14.-Anticipatory-prescribing-for-dying-patients.pdf (palliativecarescotland.org.uk)

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