Introduction Care home residents account for almost 30% of all deaths in England (NEoLCIN 2017).
Death and dying in very old age (80+) is extremely difficult to predict (Teggi, 2018), with 22% of care home residents deaths still happening in hospital (Ibid.). Inappropriate hospital admission in the last year of life has detrimental consequences for residents’ end-of-life care (EOLC) quality (Kinley-et-al., 2014), cost (Marie Curie, 2012) and hospital bed capacity (Oliver, 2020). To address this, policy streamlined the anticipatory prescribing of injectable controlled drugs (CDs) to patients expected to be dying in the community though general practice. It is now common practice for GPs to prescribe a standard set of injectable CDs (opioids and midazolam) to care home residents ahead of death and potential need. However, evidence linking anticipatory prescribing to hospital death prevention is limited (Bowers et al. 2019), and so is the evidence base on the prescription and use of injectable controlled drugs in care homes (Majumder et al. 2022).
Aims To assess whether and how anticipatory prescribing affects residents’ place of death.
To contribute to the knowledge base on the anticipatory prescribing and use of injectable CDs in care homes.
Methods Participant observation in five nursing and residential care homes in the South-West of England between May 2019 and March 2020. Observation was conducted by shadowing carers, senior carers and nurse 3–4 times a week for the duration of a 12-hour day (8am to 8pm) or night shift (8pm to 8am). Semi-structured interviews with 25 staff members (five managers, six nurses, four senior carers and ten carers) at the end of the observation period in each care home.
Results In recorded observations and staff’s accounts of residents’ deaths, residents who have GP-prescribed CDs available for them on the care home’s premises die in the care home. This occurs even when many months or years have elapsed since CDs were first prescribed. By contrast, residents without GP-prescribed CDs available for them on the care home’s premises die in hospital even in the presence of hospital discharge letters, treatment escalation plans (TEP) or ReSPECT forms advising against hospital admission. Care home nurses and senior carers report that prescribed doses of CDs are sufficient to control end-of-life symptoms in most residents, and injectable CDs are not needed in many deaths. No cases of residents being admitted to hospital for symptom control at the end of life were observed or reported by staff. Care homes employed district nurses or links with specialist palliative care service (hospices, McMillan nurses) when residents experienced intractable pain, agitation or distressing symptoms. The availability of injectable CDs on the care home’s premises allowed staff to evidence and justify the resident’s death from a clinical and legal perspective. This is linked to the legislative and regulatory framework mandating the provisions of safe and life-supporting care in care homes, and the Coroner’s framework for death reporting and investigation.
Conclusions In the care home context, the availability of GP-prescribed anticipatory medication (injectable opioids and midazolam) on the care home’s premises is considered by senior staff to provide sufficient clinical and legal evidence to withdraw of hospital-level care. If a resident with prescribed CDs dies within 14 days of their last doctor visit, no Coroner’s investigation will take place and the GP can release a medical certificate of cause of death (MCCD) based on their clinical assessment and the clinical history recorded in the resident’s care plan. Beyond providing the potential for adequate symptom-control at the end of life, anticipatory medication frames a residents’ death as expected, thus avoiding unplanned hospital admissions (and death) at the end of life.
Impact The anticipatory prescribing of CDs is a crucial tool for care home staff to allow residents die in place. No issues around the storing and monitoring of CDs in care homes were observed by this study. However, that CDs at times remain in place for many months or years before residents die calls for further investigation. Similarly, this study did not explore the disposal of unused CDs.
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