Background/Aims Anticipatory prescribing (AP) of injectable medications at the end-of-life for community patients is good practice to achieve timely symptom control (National Institute for Health and Care Excellence. Care of dying adults in the last days of life, 2015). However robust evidence to support current practice is lacking. We evaluated baseline AP practices at a South London hospice against current local guidelines.
Methods This retrospective audit looked at patient case notes and anticipatory charts (June-August 2020) using a standardised proforma including: drug choice, dose, indication and subsequent patient clinical trajectory. Anticipatory drug use, drug wastage and themes from case vignettes are presented.
Results 76 patients were reviewed, median age 80 (41-107), 66% male. 52% had a cancer diagnosis. All patients were prescribed and dispensed four medications for: pain, agitation, secretions and nausea/vomiting. There was close adherence to local guidelines (choice of drug, dose). Most commonly used drugs were: morphine 61%, midazolam 99%, glycopyrronium 97% and haloperidol 88%. 94% of patients died within three months (median 9 days). Eleven patients required admission to hospital or hospice.
64% had stats given at end-of-life, 53% for pain, 41% for agitation, 24% for secretions; only 16% needed an anti-emetic. We saw wide variation in prescribing practices for seizures at end-of-life (11 patients). Multiple health care professionals (Clinical Nurse Specialists, District Nurses and the London Ambulance Service) administered stats in and out of hours. Further training is required to ensure appropriate dose escalation and titration. Dispensing all four medications costs approximately £50 per patient; haloperidol alone accounts for 3/5ths of that cost and is not often used.
Conclusions Few patients required all four medications, where anti-emetics are needed the choice of drug warrants further review with likely cost savings. At least 50% of our medications could be dispensed by GPs rather than hospice pharmacy. Further education/training will improve individualised AP and tailored administration of medications at end-of-life, including improved confidence around seizure management. We are currently updating our guidelines to reflect this.
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