Background Common symptoms at the end-of-life include pain, breathlessness, anxiety, respiratory secretions, and nausea. National end-of-life care strategies advocate anticipatory prescribing to manage these symptoms, enhance patient care and reduce unnecessary hospital admissions. NHS Lothian palliative care guidelines have drawn on this advice and recommend that four classes of “as required” medicines are prescribed and available for all patients in the last days of life. These are analgesics, anxiolytics, and anti-secretory and anti-emetic medication.
Aims This study explored the extent to which residents in eight South Edinburgh care homes had anticipatory medications prescribed prior to death.
Results Data was collected as part of a larger project to improve palliative care in these care homes. Each care home was asked to provide data on anticipatory prescribing for the last ten residents who had died. Data on 77 residents was received, 71 of whom died in the care homes (6 died in hospital). Of the 71 who died in the care homes, 59% had some anticipatory planning medications in place: morphine for analgesia (52%); midazolam for anxiety and distress (38%); hyoscine butylbromide for respiratory secretions (21%); and levomepromazine or haloperidol for nausea (23%). Overall, 41% no anticipatory medications prescribed in the last days of life. Only 15% had prescriptions for all four medications.
Conclusions Many care home residents do not have the recommended anticipatory medications in place in the last days of life and thus may experience inadequate symptom control. Barriers to anticipatory prescribing in care homes include difficulties diagnosing dying, lack of knowledge about the guidelines, costs concerns relating to wastage of medicines and barriers around individual prescribing systems and storage. Research that explores these issues is required. In the meantime, interventions that build the skills and confidence of care home staff to diagnose dying and facilitate such prescribing are recommended.
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