Background For most people the greatest fear about dying is being in pain (ComRes, 2011; Parliamentary and Health Service Ombudsman, 2015). Anticipatory prescribing to aid prompt symptom management is well-established in end of life care (NICE, 2015). Lincolnshire has an established process for administering injectable medication in the community through a direction to administer (CD1) form completed by hand. Stakeholder feedback reported challenges with the existing system that limit pro-active, safe planning of symptom management for dying people. Lincolnshire’s rural infra-structure means that arranging medication once a person develops symptoms is time consuming and causes delays in providing symptom relief.

Aims To redesign the CD1 form and associated processes to remove barriers for completion by prescribers, to provide clear guidance, and to facilitate safe administration of medications. Ultimately we want people in Lincolnshire to receive the right care at the right time.

Methods A multi-stakeholder team updated the form and processes with user feedback. Improvements included:

• rewriting and expanding symptom management guidance

• providing a starting ‘recipe’ of anticipatory medicines that can be adjusted to individualise care

• an electronic version of the CD1 form including options to integrate into SystmOne and EMIS

• the ability to tailor the CD1 form for local prescriber preference

• additional resources including formularies for SystmOne and EMIS

• making all resources openly available on www.eolc.co.uk

Evaluation The updated CD1 form and resources were published in May 2018. Its use is being promoted alongside encouraging associated behavioural change within Lincolnshire around anticipatory prescribing. Initial feedback around clarity and ease of use is positive suggesting the revised CD1 form has addressed previous barriers around its use.

Next steps Formal user feedback survey. Data is to be collected from out of hours providers pre- and post- implementation to evaluate if the new process results in a reduction in calls to these services for symptom management in dying patients.