“Just in Case” anticipatory prescribing – a common practice in community end of life care – lacks adequate evidence, according to a new review of the literature on this topic by researchers from the Primary Care Unit at the University of Cambridge. This research alert is for GPs and healthcare commissioners.
Our Palliative and End of Life Care research programme is focused on finding ways to improve care for people in the final period of their lives. To understand more about “Just in Case” prescribing, we are now studying patient records and GPs’ views and experiences of the practice, as well as looking at policies and procedures across the UK and how anticipatory prescribing processes work.
Why this research was needed
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. The practice, known as “Anticipatory Prescribing”, is endorsed in NICE Guidance (2015) as best practice in end of life care.
The injectable medications – including strong opioids and other controlled drugs – 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.
Healthcare professionals tend to believe that the practice reassures patients and family carers, controls symptoms and prevents hospital admissions.
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 requires nurses to correctly diagnose that symptoms are not reversible and that the patient is dying. The prescriber remains accountable for the drugs, which may be open to misuse by visitors and family members.
What did the researchers do?
The team carried out a systematic review of 34 published studies into anticipatory prescribing, which was published in Palliative Medicine on 5th December 2018. The research team at the Primary Care Unit was Queen’s Nurse Ben Bowers with Dr Stephen Barclay, Dr Richella Ryan and Isla Kuhn.
What did the research find?
The research shows that the views and experiences of patients and their family carers on anticipatory prescribing have not been adequately investigated; neither has the clinical-effectiveness, cost-effectiveness or safety of the intervention.
Instead of being based on evidence, the practice is based largely on the beliefs of healthcare professionals.
Overall, this research makes it clear that the evidence is not strong enough for clinicians to draw conclusions about whether the practice does improve symptom control and patient safety or whether it can reduce hospital admissions.
What are the implications?
“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”, explains Ben Bowers, lead author for the study.
Dr Stephen Barclay, University Senior Lecturer, GP and Honorary Consultant in Palliative Medicine, says: “This review highlights large evidence gaps for the practice of anticipatory prescribing, which is now endorsed in policy documents as best practice in the UK and elsewhere. Our research group has a programme of work underway to address these important evidence gaps”.
The Cambridge Palliative & End of Life Care Group is continuing to investigate anticipatory prescribing in the community, patient and family carer views, and patient safety. Please contact Ben Bowers if you or your GP Practice would like to get involved firstname.lastname@example.org
Find out more
Read the research: 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
Published by the Primary Care Unit, University of Cambridge, with NHS Cambridgeshire and Peterborough Clinical Commissioning Group. Contact: Viv Shaw at the CCG or Lucy Lloyd at the Primary Care Unit