Doctors, nurses, and family caregivers worldwide are facing tough decisions concerning the supply and administration of medications to manage symptoms when patients are dying from COVID-19 or other conditions at home and in care homes. In many countries around the world, family caregivers are increasingly being asked to administer medications to relieve distressing symptoms for patients dying at home. This is a pragmatic step where doctors and nurses may not be available to visit all dying patients during the pandemic.
In their BMJ editorial, published today, Ben Bowers, Kristian Pollock and Stephen Barclay identify some of the challenges involved and call for training and 24/7 support for family caregivers willing to administer drugs in end-of-life care.
The advance prescribing of medications so that they are ready to be administered if and when symptoms appear in dying patients is a well-established practice in many countries. Guidance on this practice is being radically overhauled in response to the pandemic. In the UK, new NICE COVID-19 rapid guidance for community end of life care suggests changes in the drug formulations and administration methods.
Prescribers are considering drug administration by family caregivers for symptoms including pain, nausea, vomiting and agitation. The new guidance suggests administration routes that are manageable for family caregivers: via mouth cavity (buccal/sub-lingual) as well as by subcutaneous injection.
Bowers, Pollock and Barclay emphasise that the administration of drugs by family caregivers is a big ask. They explain the urgent need for adequate training and sensitive support for family caregivers, writing: ‘Clinicians often worry that they may have hastened death if a patient dies shortly after drug administration. This anxiety may be even greater for family caregivers, with some worrying that it amounts to euthanasia’. They strongly advise that family caregivers need careful training and preparation, alongside 24/7 access to telephone support to carry out this role.
As the supply of drugs to control end of life symptoms becomes less certain, they also explain that clinicians need to decide whether to continue to prescribe anticipatory medications weeks or days ahead of expected death, risking exhausting pharmacy supplies, or to delay until a patient is clearly dying.
The authors support NICE recommendations that drugs continue to be prescribed ahead of need but in small quantities. They emphasise that anticipatory prescribing continues to be necessary because patients, particularly with COVID-19, can deteriorate rapidly. Bowers, Pollock and Barclay add: ‘It would be helpful if community healthcare services could hold central stocks of the common end-of-life drugs, enabling rapid prescribing and dispensing’.
About the authors
Ben Bowers is PhD student at the Cambridge Palliative and End of Life Care Research Group at the University of Cambridge and Queen’s Nurse.
Professor Kristian Pollock is Professor of Medical Sociology at the University of Nottingham.
Dr Stephen Barclay is University Senior Lecturer in General Practice and Palliative Care at the University of Cambridge. He leads the Cambridge Palliative and End of Life Care Research Group.
Read the article
B Bowers, K Pollock, S Barclay: Administration of end-of-life drugs by family caregivers during covid-19 pandemic. Doing this safely needs training, support, and careful prescribing. BMJ 2020;369:m1615
University of Cambridge School of Clinical Medicine