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• Response to "anticipatory syringe drivers: a step too far"
  Paul Howard, John Curtin, Bev Behmer, Sandra Clawson and Dee Curless
  Published on: 18 July 2019

• Published on: 18 July 2019

  Response to "anticipatory syringe drivers: a step too far"

  • Paul Howard, Consultant in Palliative Medicine Mountbatten Hospice and St Mary's Hospital, Isle of Wight
  • Other Contributors:
    • John Curtin, Consultant in Palliative Medicine
    • Bev Behmer, Clinical Nurse Specialist and Community Palliative Care Team Leader
    • Sandra Clawson, Clinical Pharmacist in Palliative Care
    • Dee Curless, Nurse Consultant in Palliative Care

  Dear Editor,
  We read the editorial with interest. As they rightly observe, there are important problems prescribing anticipatory syringe drivers. However, we believe there are selected circumstances where it can be an important contribution to timely symptom management, provided all the following are true:
  1. There is a foreseeable distressing circumstance that can be unambiguously identified by all of the health professionals seeing the patient (including those out of hours and without ‘specialist’ experience)
  2.The medication choice and dose required is similarly foreseeable, unlikely to change, and can be safely initiated by all of the health professionals seeing the patient without additional expertise
  3.The initiation of the syringe driver reliably triggers a timely review by an appropriate clinician
  4.The patient and/or family is aware of the foreseeable need for a syringe driver, any concerns have been explored by an experienced practitioner and the anticipatory prescription done in accordance with their expressed wishes/preferences to achieve symptom control in their preferred place of care.
  Local service design will influence whether or not these criteria can be met. In our locality, patients have access to a community palliative care nurse 24hrs a day, changed circumstances are rapidly fed back by carers in the same community palliative care hub, and changes to regular medication doses can be identified because all community se...

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  Dear Editor,
  We read the editorial with interest. As they rightly observe, there are important problems prescribing anticipatory syringe drivers. However, we believe there are selected circumstances where it can be an important contribution to timely symptom management, provided all the following are true:
  1. There is a foreseeable distressing circumstance that can be unambiguously identified by all of the health professionals seeing the patient (including those out of hours and without ‘specialist’ experience)
  2.The medication choice and dose required is similarly foreseeable, unlikely to change, and can be safely initiated by all of the health professionals seeing the patient without additional expertise
  3.The initiation of the syringe driver reliably triggers a timely review by an appropriate clinician
  4.The patient and/or family is aware of the foreseeable need for a syringe driver, any concerns have been explored by an experienced practitioner and the anticipatory prescription done in accordance with their expressed wishes/preferences to achieve symptom control in their preferred place of care.
  Local service design will influence whether or not these criteria can be met. In our locality, patients have access to a community palliative care nurse 24hrs a day, changed circumstances are rapidly fed back by carers in the same community palliative care hub, and changes to regular medication doses can be identified because all community services use a single integrated electronic health record. The following examples illustrate situations in which we would consider anticipatory prescribing for patients wishing to remain at home and for symptom relief to be prioritised.
  In a patient at risk of recurrence of malignant bowel obstruction, where no further surgical or oncological intervention was possible, a situation can be unambiguously identified (“colicky abdominal pain combined with 2 or more vomits within 24 hrs”), in which the need for specific medication is foreseeable (levomepromazine 6.25mg/24hrs and hyoscine butylbromide 60mg/24hrs). Further, in the context of our integrated team, the need for review can be considered at the following morning’s community hub meeting.
  In seizures from cerebral metastases - well controlled with levetiracetam 500mg twice daily - but who is at risk of losing their oral route, a situation can be unambiguously identified (“unable to take their oral levetiracetam”) in which the need for specific medication is foreseeable (“levetiracetam 1000mg/24hrs”). The need for timely review can be similarly considered. In this instance, the shared electronic record can be used by the prescriber to see if another prescriber has altered the oral levetiracetam dose that requires the anticipatory prescription to be amended.
  Such anticipatory prescribing is contingent on effective communication within a highly integrated community team. It is our experience that, in selected patients, in such a structure anticipatory prescribing of syringe drivers can provide an important contribution to timely symptom management.

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  Conflict of Interest:
  None declared.

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