Table 1

AP practice changes during COVID-19

Changes toYesNoUnsureIllustrative comment examples
Which drugs are prescribed?98 (38%)146 (56%)17 (7%)
  • More off-licence drug use #83 CONS.

  • Including non-injectables, for example, buccal midazolam in case no nurse can attend #14 CONS.

  • Changing with availability: hyoscine patch for glycopyrronium #253 CNS.

The quantities of drugs prescribed?90 (35%)137 (53%)34 (13%)
  • Prescribing smaller quantities to preserve stocks #51 CONS.

  • Larger doses for ARDS: may need repeated sooner #127 TRAIN.

  • Continuing normal practice #217 DOC.

Drug doses/dose ranges prescribed?75 (29%)163 (63%)23 (9%)
  • Higher starting doses for distress, especially levomepromazine #241 CONS.

  • Up to 1-hourly if dyspnoea or distress persist #102 CONS

  • Quicker escalation to larger doses for some #99 GP.

  • Wider ranges and more prescribed to cover every eventuality #83 CONS.

Arrangements for drugs and supporting documents to be in the home/care home?96 (36%)135 (52%)31 (12%)
  • Authorisation sheet electronic #240 GP

  • ‘Grab bags' with anticipatory meds available in emergency department #248 CONS.

  • Stores with army to deliver: 'just in case' changed to 'just in time' #134 CONS.

Route of administration, especially the sublingual/buccal route?122 (47%)124 (48%)15 (6%)
  • Oral/buccal routes give patients/relative more control without HCP #84 CONS.

  • Subcutaneous route first, buccal/transdermal use if availability of SC drugs affected #64 CNS.

  • Lorazepam, hyoscine and fentanyl patches alternatives if SC meds not available #5 CONS.

Person administering AP drugs, especially family/informal carers or social care colleagues?97 (37%)136 (52%)28 (11%)
  • Family offered chance to learn if they want to #217 DOC.

  • Care home staff rather than district nurse after phone advice #213 GP.

  • Already have carer administering SC policy #244 CONS.

Telephone or other advice and support for AP, including family/social care administration?127 (49%)113 (43%)21 (8%)
  • Advice line 17:00–21:00. Increased our cover on weekend and Bank Holiday #10 CNS.

  • Decision for AP made on FaceTime #46 OTHER.

  • Much more remote working now; complete change in practice #150 GP.

The use of phone or video to support AP practice?165 (63%)78 (30%)18 (7%)
  • Care now via telephone or video including AP advice #131 DOC.

  • Reduces risk of transmission and aids completion of forms when patient dies #176 GP.

  • Video review to make decision patient is dying; may need visit in person #240 GP.

The prescribing of AP medications for patients with non-COVID-related illness?63 (24%)181 (69%)17 (7%)
  • Any patient could develop COVID, anticipating higher likelihood of agitation #71 TRAIN.

  • Consider non injectables for non-complex #22 CONS.

  • Preparing for how to cope without syringe drivers #150 GP.

The use of syringe drivers?79 (30%)165 (63%)17 (7%)
  • Few patients with COVID need syringe pumps as they die very quickly #240 GP.

  • Most dying patients with COVID easily managed by stat doses #103 CONS.

  • Patches due to equipment and DN resources #39 TRAIN.

  • AP, anticipatory prescribing; CNS, palliative care specialist nurse; CONS, palliative medicine consultant; DN, district nurse; DOC, doctor; GP, general practitioner; HCP, health care professional; OTHER, other professional group; TRAIN, palliative medicine trainee.