a) Anticipatory Prescribing in community end of life care during the COVID-19 pandemic
Research contact
Dr Bárbara Antunes, NIHR ARC Research Associate
Email: bc521@medschl.cam.ac.uk
ORCiD: 0000-0003-1655-7391
Twitter: @B_CP_Antunes
Project length
2020 – 2021
Summary
Anticipatory Prescribing (AP) is the prescribing of injectable medications for community end of life care in advance of need, to ensure that appropriate medication is readily available should troubling symptoms arise in the final phase of life. We conducted a web-based survey in April 2020 to investigate UK and Ireland clinicians’ experiences concerning changes in AP during the COVID-19 pandemic. Two hundred and sixty-one replies were received between 9 and 19 April 2020 from clinicians in community, hospice and hospital settings across all areas of the UK and Ireland. Changes to AP local guidance and practice were reported: route of administration (47%), drugs prescribed (38%), total quantities prescribed (35%), doses and ranges (29%). Concerns over shortages of nurses and doctors to administer subcutaneous injections led 37% to consider drug administration by family or social caregivers, often by buccal, sublingual and transdermal routes. Clinical contact and patient assessment were more often remote via telephone or video (63%). We conducted follow up interviews to some of those participants to have a more in-depth understanding of those changes and if they were sustained 6 months after the first COVID wave. Analysis of those interviews is underway.
Funding
National Institute for Health Research (NIHR) Applied Research Collaboration East of England (ARC EoE) programme.
Outputs
- Antunes B, Bowers B, Winterburn I, et al. Anticipatory prescribing in community end-of-life care in the UK and Ireland during the COVID-19 pandemic: online survey. BMJ Supportive & Palliative Care 2020;10:343-349. https://spcare.bmj.com/content/10/3/343
- Presentation at Hospice UK Zoom ECHO sessions on the 8th of July 2020 hospiceuk.org/docs/default-source/echo/covid-19-echo/max-final-slides.pdf?sfvrsn=2
- Bowers B, Pollock K, Barclay S. (April 2020) “Administration of end-of-life drugs by family caregivers during covid-19 pandemic. Doing this safely needs training, support and careful prescribing”. British Medical Journal: 369: m1615. doi:10.1136/bmj.m1615
b) Just in Case Drugs Study (JIC Study)
Research contact
Ben Bowers, NIHR School for Primary Care Research PhD Student and Queen’s Nurse
Email: bb527@medschl.cam.ac.uk
ORCiD: 0000-0001-6772-2620
Twitter: @Ben_Bowers__
Project length
2020 – 2022
Summary
Widespread practice in the UK, ‘Just in Case’ drugs seeks to reduce crisis hospital admissions and improve symptom control at home. To date, no research study has looked into how patients and their informal carers (family and friends) view and experience Just in Case drug practice. This qualitative study, involving 6 patients, 9 informal carers and 6 health professionals, helps to address this gap. Field work was completed in December 2020. The study is part of Ben Bowers’ PhD research.
Patients and informal caregivers took part in one to three research conversations, and health professionals in one. The current study analysis is looking for patterns and differences in views, experiences, and Just in Case drugs prescribing and administration practices. Findings will be shared widely with service providers, clinicians and the public to help inform future practice.
Funding
National Institute for Health Research (NIHR) School for Primary Care Research Studentship
NIHR Short Placement Award for Research Collaboration (SPARC) 2020-21
RCN Foundation Professional Bursary Award 2019
Outputs
- Bowers B, Pollock K, Barclay S. Administration of end-of-life drugs by family caregivers during covid-19 pandemic. British Medical Journal 2020; 369: m1615 https://www.bmj.com/content/369/bmj.m1615
- Cambridge News 5 October 2020: Cambridge nurse who cares for people at the end of their lives shortlisted for nursing award
- Bowers B, Lovick R, Pollock K, Barclay S. Patient and public involvement in general practice research. British Journal of General Practice 2020; 70 (694): 220-221 https://doi.org/10.3399/bjgp20X709457
c) Anticipatory Prescribing in Terminal Care Study (APT Study)
Research contact
Ben Bowers, NIHR School for Primary Care Research PhD Student and Queen’s Nurse
Email: bb527@medschl.cam.ac.uk
ORCiD: 0000-0001-6772-2620
Twitter: @Ben_Bowers__
Project length
2018 – 2020
Summary
Retrospective patient record review study investigating the current practice of issuing and using end of life anticipatory prescribing (‘Just in Case’ drugs) across a range of illnesses in the community. We reviewed 329 patient records (30 per practice) across 11 General Practitioner (GP) practices in Cambridgeshire and Hertfordshire. We identified if and when drugs were prescribed from GP records and the administration of these drugs from community nursing records. The main analysis is now completed, and papers have been submitted for publication. The study is part of Ben Bowers’ PhD research.
The research provides novel and detailed information on current anticipatory prescribing practice, prescribing and administration circumstances, and variations in care. This new knowledge is being shared with members of the public and clinicians to inform personalised care, practice development and interprofessional team working.
Funding
National Institute for Health Research (NIHR) School for Primary Care Research Studentship
RCN Foundation Professional Bursary Award 2018
Outputs
- Bowers B, Pollock K, Dickman A, Ryan R, Barclay S. Anticipatory syringe pumps: benefits and risks. BMJ Supportive & Palliative Care Published Online First: 19 January 2021. http://dx.doi.org/10.1136/bmjspcare-2020-002735
d) Anticipatory prescribing in community end of life care
Research contact
Ben Bowers, NIHR School for Primary Care Research PhD Student and Queen’s Nurse
Email: bb527@medschl.cam.ac.uk
ORCiD: 0000-0001-6772-2620
Twitter: @Ben_Bowers__
Project length
2017 – 2019
Summary
As a NIHR ARC (CLAHRC) Fellow, Ben Bowers conducted 1) a systematic review on anticipatory prescribing (‘Just in Case’ drugs) in adult end of life care in the community and 2) a qualitative study of General Practitioners’ decisions about prescribing end of life anticipatory medications.
Ben Bowers’ PhD research awarded by the NIHR School for Primary Care Research, takes this work further through the Anticipatory Prescribing in Terminal Care (APT).
Funding
NIHR Collaboration for Leadership in Applied Health Research and Care (CLAHRC) Fellowship
National Institute for Health Research (NIHR) School for Primary Care Research Studentship
Outputs
- Bowers B, Ryan R, Kuhn I, Barclay S. Anticipatory prescribing of injectable medications for adults at the end of life in the community: A systematic literature review and narrative synthesis. Palliative Medicine 2019. 33(2): 160-177 https://doi.org/10.1177/0269216318815796
- Bowers B, Barclay SS, Pollock K, Barclay S. General Practitioners’ decisions about prescribing end-of-life anticipatory medications: a qualitative study. British Journal of General Practice 2020; 70(699): e731-739.https://doi.org/10.3399/bjgp20X712625
- Bowers B, Ryan R, Hoare S, Pollock K, Barclay S. Anticipatory syringe drivers: A step too far. BMJ Supportive and Palliative Care 2019; 9: 149-150 http://dx.doi.org/10.1136/bmjspcare-2018-001728
- Bowers B, While A. Getting anticipatory prescribing right in end-of-life care. British Journal of Community Nursing 2019; 21(6): 274-277
- NIHR School for Primary Care Research News 9 May 2019: Nursing award for Cambridge Palliative and End of Life Care research
e) End-of-Life Controlled Drugs in U.K. Care Homes: A Systematic Literature Review and Narrative Synthesis
Research contact
Megha Majumder, Abbeyfield Foundation PhD Student
Email: mm2426@medschl.cam.ac.uk
Twitter: @megmajumder
Project length
2020 – 2021
Summary
Background: Schedule 1, 2 and 3 controlled drugs (CDs): strong opioids (excluding codeine, dihydrocodeine, and tramadol) and midazolam primarily (oral or injectable) are common medicines for palliating end-of-life symptoms for care home residents in the UK. These medicines are susceptible to misuse and abuse. While prescribing controlled medicines to provide end-of-life symptom relief is a well-established practice, the evidence base to support this practice is lacking.
Aim: To review the published evidence concerning the prescribing of CDs for care home residents at the end of life in the UK.
Methods: Systematic review and narrative synthesis. Data sources include Medline, Embase, PsycINFO, Web of Science, and Cochrane Library, searched from January 2000 up to January 2021. Included papers presented new empirical data on the prescribing of Schedule 1, 2 and 3 CDs for symptom control in UK care home residents at the end of life. Gough’s Weight of Evidence framework was used to appraise the quality of research.
Results: The search yielded 1062 papers, of which 14 have been included in data synthesis. While GPs primarily prescribe CDs, nurses administer them in care homes. Nurses reported feeling inadequately trained, and the attitudes of residents and family members regarding the prescribing process remain largely unknown. Specific aspects of the process are entirely unexplored in the literature including the storage, monitoring, and disposal of CDs. The lack of an evidence base does not allow for robust conclusions to be drawn regarding the effectiveness and comfort CDs are meant to provide.
Conclusion: The practice and policy of storing, monitoring, and disposing end-of-life CDs in care homes, alongside the lack of high quality evidence exploring patient and family members’ perspectives, are significant gaps in the literature and require critical examination in light of the COVID-19 pandemic and rapidly-changing policies around medicines use in care homes.
Funding
Abbeyfield Trust / Research Foundation
f) End of Life Care prescribing in care homes and in the community in the UK: a mixed-methods study of local policies and procedures.
Research contact
Megha Majumder, Abbeyfield Foundation PhD Student
Email: mm2426@medschl.cam.ac.uk
Twitter: @megmajumder
Project length
2021 – 2021
Summary
Background: The COVID-19 pandemic has led to major changes in the prescribing and use of End-of-Life Care drugs in the community, in particular: changes in AP drugs and doses; greater use of appropriately selected and trained family / lay carers to administer EOLC drugs; national guidance that EOLC drugs prescribed for a care home resident can now be repurposed for another resident if urgently needed.
Aim: To investigate the availability of local / regional policies and procedures to guiding EOLC prescribing practice in community End-of-Life care across the UK, with a focus on changes introduced during the COVID-19 pandemic, in respect of:
- Anticipatory prescribing at home and in care homes
- Syringe drivers at home and in care homes
- Repurposing of medicines at the end of life
- Family carer administration of end of life care medicines
Methods: Relevant stakeholders from a sample of CCG areas (or equivalent) from across the UK were identified from our previous study. Additional colleagues from across the UK were approached to participate through their professional organisations including: Association for Palliative Medicine of the United Kingdom and Ireland, Association of Supportive and Palliative Care Pharmacists, Queen’s Nursing Institute, and Hospice UK. We contacted these colleagues by email, inviting them to send us copies of policies, guidance, standard operating policies and patient information leaflets in their area concerning:
- Anticipatory prescribing at home and in care homes
- Syringe drivers at home and in care homes
- Repurposing of medicines at the end of life
- Family carer administration of end-of-life care medicines
- Other supporting documents concerning the above
Data analysis: We are in the process of developing a data extraction sheet consisting of questions based on the literature, the clinical experience of members of the research team and scoping of online national and local policies. We will conduct domain and content analysis to determine guidance gaps, then compare guidance documents between responding regions in the following areas:
- decision to prescribe,
- prescribing and dispensing,
- monitoring, storage and set-up,
- assessment and administration, and
- post-death procedures for AP at home and in care homes; syringe drivers; the repurposing of medicines at end of life; and family carer administration of end-of-life care medicines.
Funding
Abbeyfield Trust / Research Foundation
g) Anticipatory prescribing in end-of-life care in U.K. care homes: a qualitative interview study
Research contact
Megha Majumder, Abbeyfield Foundation PhD Student
Email: mm2426@medschl.cam.ac.uk
Twitter: @megmajumder
Project length
The proposed start date for participant recruitment is March 2021 and it is anticipated that data collection will continue until September 2021. The following timeline outlines the timeframes for the different phases of the study:
- Recruitment of care homes via care home managers in Cambridgeshire: March 2021
- Interviews with care home managers: April to July 2021
- Interviews with care home staff (nurses, practitioners, carers): May 2021 to July 2021[2]
- Data collection and concurrent data analysis (transcription, reading, initial commenting): April 2021 to August 2021
- Further data analysis (narrative analysis, phenomenological analysis) following completion of interviews: August to October 2021
- Writing and publication of journal papers: October to December 2021
- Writing of PhD dissertation and conference presentations: January to June 2022
Summary
We will be conducting a qualitative interview study with care home managers, staff members, visiting clinicians, and pharmacists in care homes across Cambridgeshire. We are interested in addressing the following questions. With regard to AP in U.K. care homes:
- For whom and by whom are AP medicines prescribed?
- How are AP medicines stored and monitored?
- For whom and by whom are AP medicines administered?
- How are AP medicines disposed of after a resident’s death?
- What are the views of care home staff and other health and social care professionals concerning these issues?
These data will be analysed through a hermeneutic phenomenological and idiographic lens, generating case-studies of the AP process in individual care homes at two levels:
- Mechanics of AP within nursing homes: how AP operates in each of the participating nursing homes. Specifically, by and for whom AMs are prescribed and administered, and how AMs are monitored and disposed of.
- Perspectives about AP within nursing homes: How AP is perceived and experienced by nursing home managers, staff, clinicians, and/or pharmacists as they negotiate their space, place, and relationships within the institution at large.
Funding
Abbeyfield Trust / Research Foundation