GPs looking after patients close to the end of life at home prefer to prescribe ‘anticipatory medications’, also known as ‘Just in Case’ drugs, weeks ahead of likely need whenever possible, according to a new study from the Cambridge Primary Care Unit.
Anticipatory medications are intended to relieve symptoms that might emerge as patients approach the end of life. They are prescribed in advance so that the injectable drugs can be administered without delay when and if they are needed.
It is recommended practice in the UK, New Zealand and Australia for GPs to prescribe anticipatory medications in advance of need for patients approaching the end of their lives at home.
Little is known about the decision-making processes in anticipatory prescribing, or about how GPs discuss the prescribing process with patients and families. This study throws new light on the GP role in prescribing anticipatory medications and highlights the need for skilled clinical assessment before the medications are administered.
The research team carried out in-depth interviews with thirteen GPs in one English county and developed a series of themes from the data.
Anticipatory medications were seen by the GPs as a tangible intervention they could offer patients approaching death, when more active medical options became inappropriate: ‘something we can do’. All the GPs interviewed highlighted that it was essential to have the drugs in place as an insurance plan which could be used to provide end-of-life symptom relief if needed:
“There’s no crystal ball and it’s better to have them in place than face some sort of crisis”. GP
Anticipatory medications were used as a sign to alert other visiting healthcare professionals to the terminal nature of the patient’s condition. Having the drugs in the home were seen to send a clear signal that the focus of care should be on providing end-of-life symptom control. Their presence also enabled doctors who did not know the patient to make remote care decisions:
“I think in one way it makes life easier. Decisions can be made over the phone, then, with the district nurses. It makes it clear to everyone what’s going on, which I think is useful”. GP and out-of-hours doctor
While the GPs recognised that the prescribing of anticipatory medications was a harbinger of death for patients and their families, they preferred to discuss and prescribe anticipatory medications weeks before death was expected whenever possible.
“I tend to do it [prescribe drugs] at the same time as we agree that we’re not going to resuscitate or admit someone to hospital”. GP
After prescribing medications, the GPs reported that they relied on nurses to assess when to administer drugs and keep them updated about their use. This delegation of the responsibility for the decision to administer the drugs to often unknown nurses or doctors caused some concern:
“There are some issues about writing up potentially life terminating drugs if used in an inappropriate way… to be used at the discretion of a third party, with no connection between the third party who initiates them and the prescriber”. GP
Ben Bowers, lead author and member of the Cambridge Palliative and End of Life Care Research Group commented:
“Our study is the first to identify that anticipatory medications are used as a sign to alert other visiting clinicians to the terminal nature of the patient’s condition. Having the drugs in place enabled unfamiliar doctors and nurses to make care decisions, sometimes without visiting”.
“At a time when resources in the community are increasingly stretched, there is a danger that anticipatory medications may be started without prior assessment of the patient by an experienced clinician, including consideration of the causes and potential reversibility of the patient’s symptoms”.
“Accounts of using the presence of anticipatory medications to guide care decisions in circumstances when care plans and clinical information had not been adequately shared between services is potential cause for concern”.
This study was funded by the National Institute for Health Research (NIHR) Collaboration for Leadership in Applied Health Research and Care (CLAHRC) East of England and the NIHR School for Primary Care Research.
Read the research paper
B Bowers, S S Barclay, K Pollock and S Barclay GPs’ decisions about prescribing end-of-life anticipatory medications: a qualitative study BJGP 7 Sept 2020
Lucy Lloyd, Communications Manager, Primary Care Unit