A review of the anticipatory prescribing evidence-base
Bowers B, Ryan R, Kuhn I, Barclay S (2019) Anticipatory prescribing of injectable medications for adults at the end of life in the community: A systematic literature review and narrative synthesis. Palliative Medicine 33(2): 160-177 https://doi.org/10.1177/0269216318815796
Relevance of the research
The Anticipatory Prescribing of injectable medications to provide end-of-life symptom relief is an established community practice in a number of countries. The knowledge base to support this practice is unclear. The researchers carried out a systematic literature review and narrative synthesis to clarify the current knowledge base and the priority areas for future research.
Significance of the research
The Independent Review of the Liverpool Care Pathway found that the use of Anticipatory Prescribing without adequate explanation or justification led to families being concerned about over-sedation and the medication hastening death. Despite these concerns, subsequent National Institute for Health and Care Excellence (NICE) end-of-life care guidance continues to advocate “individualised” Anticipatory Prescribing as best practice. However, the same guidance highlighted the limited evidence base concerning Anticipatory Prescribing practice, and the risk that medications are sometimes prescribed in a ‘blanket-like fashion’ rather than tailored to patients’ needs.
In summary, it is unclear whether anticipatory prescribing is acceptable to all involved, clinically effective or cost-effective.
With regard to Anticipatory Prescribing of injectable medications for adults in the community approaching the end of their lives:
- What is current practice?
- What are the attitudes of patients?
- What are the attitudes of family carers?
- What are the attitudes of community healthcare professionals?
- What is its impact on patient comfort and symptom control?
- Is it cost-effective?
Methods: The review search identified 5099 titles, with 34 papers included in the synthesis.
Key findings: Healthcare professionals believe anticipatory prescribing provides reassurance, effective symptom control, and helps to prevent crisis hospital admissions. The attitudes of patients towards anticipatory prescribing remain unknown. Anticipatory prescribing is a low-cost intervention. There is inadequate evidence to allow conclusions to be drawn about its cost-effectiveness, safety, impact on patient-reported symptoms, and comfort or prevention of crisis hospital admissions.
Anticipatory prescribing is recommended and widespread practice in many countries, despite an inadequate knowledge base. Policy and practice are running ahead of the evidence, based largely on the belief of healthcare professionals that it reassures patients and their family carers, effectively controls symptoms and prevents crisis hospital admissions.
The views and experiences of patients and their family carers towards anticipatory prescribing need urgent investigation. Further research is needed to investigate the impact of anticipatory prescribing on patients’ symptoms and comfort, patient safety, and hospital admissions.