The prescription and dispensing of injectable medications to provide end of life symptom relief for patients approaching the end of their lives in the community, in advance of clinical need, is established practice in the UK and other countries. But a new review of the research literature reveals that this widespread practice is based on an inadequate evidence-base.
Injectable medications are typically prescribed so that visiting nurses or doctors can administer them if pain, nausea and vomiting, agitation and respiratory secretions arise in the final days of life. The practice, known as “Anticipatory Prescribing” is endorsed in NICE Guidance (2015) as best practice in end of life care.
34 studies were reviewed by Ben Bowers as part of his NIHR School for Primary Care Research PhD research at the Primary Care Unit of the University of Cambridge, working with Dr Stephen Barclay, Dr Richella Ryan and Isla Kuhn. The review, published today in Palliative Medicine, shows that the practice is based largely on the belief of healthcare professionals that anticipatory prescribing reassures patients and their family carers, effectively controls symptoms and prevents hospital admissions. The views and experiences of patients and their family carers have not been adequately investigated; nether has the clinical-effectiveness, cost-effectiveness or safety of the intervention.
There is inadequate evidence to draw conclusions about the effectiveness of anticipatory prescribing on symptom control, patient comfort, hospital admissions or the acceptability to patients and family carers. There is potential risk for the drugs to be prescribed in a “blanket-like fashion” rather than tailored to patients’ needs. Our study underscores the importance of developing the evidence-base for patient-centred care”.
– Ben Bowers, PhD Student and Queen’s Nurse, Primary Care Unit
Anticipatory prescribing of injectable medication in the community has become a central component of end of life care in the UK, Australia and New Zealand. It ensures rapid access to medications, particularly out-of-hours when sourcing medication can be delayed, enabling rapid administration of drugs by visiting doctors and nurses.
However, prescribing strong injectable medications ahead of need has potential risks. Appropriate prescribing relies on clinicians correctly identifying that patients are approaching their last days of life. Appropriate administration of the medication is dependent on nurses correctly diagnosing that symptoms are not reversible and that the patient is dying. This is a skilled judgement requiring discussion with senior colleagues. The prescriber remains accountable for the drugs, including strong opioids and other controlled drugs, which may be in the home for weeks and are open to misuse by visitors and family members.
This is the first systematic review of the published literature on this important area of end of life care. It highlights several large gaps in the evidence base for the practice of anticipatory prescribing, which is now widespread and is endorsed in policy documents as best practice in end of life care. The review identified that the views and experiences of patients remain unknown and the safety of anticipatory prescribing has never been investigated. Although a low-cost intervention, there is inadequate evidence to draw conclusions about its clinical effectiveness or cost-effectiveness. Policy and practice are running ahead of the evidence”.
– Dr Stephen Barclay, University Senior Lecturer, GP and Honorary Consultant in Palliative Medicine
Find out more
Read the review: Ben Bowers, Stephen Barclay, Richella Ryan, Isla Kuhn: Anticipatory prescribing of injectable medications for adults at the end of life in the community: A systematic literature review and narrative synthesis. Palliative Medicine, 05 December 2018
Cambridge Palliative and End of Life Care Group at the Primary Care Unit, University of Cambridge
Media queries: Lucy Lloyd, Communications Manager, Primary Care Unit
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Ben Bowers and Dr Stephen Barclay were funded for this work by the National Institute for Health Research (NIHR) Collaboration for Leadership in Applied Health Research and Care (CLAHRC) East of England. The views expressed are those of the authors and not necessarily those of the NHS, the NIHR or the Department of Health and Social Care.