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Anticipatory Prescribing for adults at end of life Stephen Barclay, Ben Bowers, Bárbara Antunes, Kristian Pollock, Megha Majumder, Richella Ryan, Michael P Kelly, Isla Kuhn, Anna Spathis, Sam Barclay, Andrew Dickman, Isaac Winterburn, Robert Brodrick, Iain Lawrie, Rob George

What is Anticipatory Prescribing?

Anticipatory Prescribing is the prescription and dispensing of injectable medications to a named patient, ahead of possible need, for use if symptoms arise in the final days of life. Medications are typically prescribed for symptoms of pain, nausea and vomiting, agitation, and respiratory secretions. The intervention seeks to improve symptom control at home and reduce crisis hospital admissions.

Anticipatory Prescribing is considered to be an important intervention in supporting patients and families who wish to have last days of life care at home. Once prescribed, the medications are kept in the home (or care home) and typically are used by visiting doctors or nurses if the patient is dying and requires symptom relief.

The challenge

The Covid-19 pandemic has accelerated the practice of Anticipatory Prescribing; more terminally ill patients are having end-of-life care at home and in care homes. This upward trend of deaths in community settings will continue in coming years, as the population ages and more people die from chronic life limiting conditions. Although Anticipatory Prescribing is recommended practice in the UK, and a number of other countries, the evidence base to support this common practice is unclear.

Researchers in the Palliative & End of Life Care Group in Cambridge (PELiCam) are leading a programme of research concerning Anticipatory Prescribing to help inform evidence-based clinical practice:

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.

Review questions

With regard to Anticipatory Prescribing of injectable medications for adults in the community approaching the end of their lives:

  1. What is current practice?
  2. What are the attitudes of patients?
  3. What are the attitudes of family carers?
  4. What are the attitudes of community healthcare professionals?
  5. What is its impact on patient comfort and symptom control?
  6. Is it cost-effective?

The research

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.

The outcomes

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.

Changes in anticipatory prescribing practices during Covid-19

Antunes B, Bowers B, Winterburn I, Kelly MP, Brodrick R, Pollock K, Majumder M, Spathis A, Lawrie I, George R, Ryan R, Barclay S. (2020) Anticipatory prescribing in community end-of-life care in the UK and Ireland during the COVID-19 pandemic: online survey. BMJ Supportive & Palliative Care; http://dx.doi.org/10.1136/bmjspcare-2020-002394

Relevance of research

Anticipatory prescribing seeks to optimise end-of-life symptom control in community settings. The number of people dying in care homes and at home has risen dramatically during the COVID-19 pandemic in the UK and other countries. Anticipatory prescribing guidance and practice has changed in response. The evidence base for current anticipatory prescribing practice is sparse, so learning about the changes in practice during the pandemic is critical.

Significance

The end of life is an extremely important phase of life for patients, families, close friends and healthcare providers. Anticipatory prescribing is considered a key intervention in enabling optimal symptom control if it is aligned with patients’ and families wishes. We need to ensure anticipatory prescribing is done safely, with low risks for all involved and in a way that will contribute for patient and families’ well-being throughout the end-of-life journey.

The research

A web-based survey in April 2020 investigated UK and Ireland clinicians’ experiences concerning changes in anticipatory prescribing during the first wave of the COVID-19 pandemic and their recommendations for change. Two hundred and sixty-one replies were received from clinicians in community, hospice and hospital settings across all areas of the UK and Ireland.

The outcomes

This study revealed rapid changes in anticipatory prescribing practice was underway and under consideration in many areas of the UK and Ireland. Clinicians were considering increasing the use of alternative medications to address stock shortages, new routes of administration, family caregiver administration, or prescribing drugs closer to death and in smaller quantities. There were calls to revise pharmaceutical regulations to permit repurposing of anticipatory prescribing medications in care homes, wider community drug access, and recycling unused medications returned to pharmacies. Reflecting broader changes in clinical practice during the pandemic, more community end-of-life care medical consultations and anticipatory prescribing was being undertaken remotely, with increased 24 hours availability. These changes will potentially significantly affect care during the pandemic and in the future.

General Practitioners decisions about prescribing anticipatory medications

Bowers B, Barclay SS, Pollock K, Barclay S (2020) General Practitioners’ decisions about prescribing end-of-life anticipatory medications: a qualitative study. British Journal of General Practice; 70(699) e731-739 https://doi.org/10.3399/bjgp20X712625

Relevance of research

The prescribing of anticipatory medications to provide symptom relief in last days of life care is recommended practice in the UK, Australia, and New Zealand. General Practitioners (GPs) have a central role in decisions about prescribing anticipatory medications to help control symptoms at the end of life. The GP remains accountable for the medications they have prescribed, including strong opioids, which may be in the home for weeks. Once prescribed, permission has been granted for nurses to use anticipatory medications based on their clinical assessment that the person is dying and has distressing symptoms.

Significance

Little is known about GPs’ decision-making processes in prescribing anticipatory medications, how they discuss this with patients and families, or the subsequent use of prescribed drugs. This study explores GPs’ decision-making processes in the prescribing and use of anticipatory medications for patients at the end of life.

The research

Design and setting: This interpretive descriptive study was conducted in an English county with a mixture of urban and rural communities. Interviews were undertaken with GPs from a range of practices about their views and experiences of decision-making about end-of-life anticipatory medications.

Methods: Semi-structured interviews were conducted with a purposive sample of 13 GPs in 2017. Interview transcripts were analysed inductively using thematic analysis.

Key findings: This study found that GPs are keen to prescribe anticipatory medications weeks ahead of death even if they are unlikely to be needed. Anticipatory medications were a tangible intervention GPs felt they could offer patients approaching death.

The prescribing of anticipatory medications was recognised as a harbinger of death for patients and their families. Nevertheless, most GPs preferred to discuss and prescribe anticipatory medications as early as was possible and clinically appropriate. GPs often recall framing anticipatory medications as their clinical recommendation to ensure that the prescription is accepted by patients and their families.

GPs were very aware that they remained responsible for anticipatory medications once prescribed. They had little knowledge or control over when they were used. They relied on nurses to assess when to administer medications and keep them updated about their use. Having easy access to nurses was perceived to be crucial in facilitating good end-of-life care and the appropriate use of anticipatory medications.

The outcomes

GPs view anticipatory medications as key to symptom management for patients at the end of life. The medications are often presented as a clinical recommendation to ensure patients and families accept the prescription. They need regular access to nurses and rely on their skills to administer medications appropriately. Patients’ and families’ experiences of anticipatory medications, and their preferences for involvement in decision making, warrant urgent investigation.

Anticipatory syringe pumps: benefits and risks

Bowers B, Pollock K, Dickman A, Ryan R, Barclay S. Balancing the benefits and risks of anticipatory syringe pumps. BMJ Supportive & Palliative Care Published Online First: 19 January 2021 http://dx.doi.org/10.1136/bmjspcare-2020-002735

Relevance of research

In safe hands, syringe pumps facilitate appropriate and effective control of pain and other symptoms for patients who are no longer able to swallow or absorb oral medication, commonly at the end of life. The Gosport War Memorial Hospital Independent Inquiry has increased public and clinician awareness about syringe pumps (drivers) for continuous subcutaneous delivery of opioids and other medications at the end of life. The inquiry found that at least 456 patients died where opioids had been prescribed and administered in unjustified doses, commonly via syringe pumps. In an overstretched clinical climate in which clinicians are encouraged to plan ahead to optimise patient care, the Gosport inquiry is a timely warning of the potential dangers of ‘anticipatory syringe pumps’ prescribed in anticipation of future symptoms at the end of life.

Significance

Anticipatory prescribing guidance from the National Institute for Health and Care Excellence (NICE), Healthcare Improvement Scotland and the British Medical Association lacks clarity about anticipatory syringe pumps. NICE guidance simply advises ensuring suitable anticipatory medicines and routes are prescribed as early as possible. There is an urgent need for research to guide safe and effective practice in this area.

The research

Immediately pre-COVID, the researchers completed a retrospective observational study of anticipatory medication practice in primary care. They reviewed 329 patient records from 11 General Practitioner (GP) practices (30 most recent predictable deaths per practice) in two English counties. Anticipatory syringe pumps were prescribed for 49/167 (29.3%) of patients issued with anticipatory medications, with considerable variation in frequency between GP practices, ranging from 10/14 patients (71.4%) to 1/16 patients (6.3%). Prescription timing varied from 536 to 0 days before death (median 5.5). There were notably diverse prescribing cultures: median time from prescription to death ranged from 27 to 2 days across individual GP practices.

A parallel research review of a random sample of 28 local community anticipatory prescribing policies and drug authorisation charts in England found explicit guidance regarding the appropriateness of anticipatory syringe pumps was in place in only 12 areas (paper in preparation). This suggests unregulated practice exists in some areas where anticipatory syringe pumps are used, without robust governance and documentation systems to support practice. There is a real risk of administration errors in the absence of reminders and checks to ensure oral medicines are stopped, and existing transdermal medicines are considered, when anticipatory syringe pumps are commenced.

The outcomes

There is a danger that specialist palliative care practice for patients with complex needs is being followed in General Practice for those with less complex symptom profiles. Concurring with the Association of Supportive and Palliative Care Pharmacy (ASPCP) recent position statement, the researchers recommend syringe pumps should only be prescribed after a face-to-face clinical review by a skilled prescriber to consider causes of deterioration and associated symptoms, evaluate reversibility, establish a dying diagnosis and appraise the effectiveness of previously administered oral and ‘as required’ (PRN) drug injections. In the relatively unusual circumstances in which an anticipatory syringe pump is appropriate, it is important to ensure that prescribers regularly reassess the patient’s needs and review the prescription accordingly.

End-of life care website

http://www.phpc.cam.ac.uk/pcu/research/research-groups/end-of-life-care/

Additional paper of interest

Administration of end-of-life drugs by family caregivers during covid-19 pandemic. Bowers B, Pollock K, Barclay S. British Medical Journal 2020; 369: m1615 https://doi.org/10.1136/bmj.m1615

Links to any relevant publications and additional resources/organisations:

GPs’ decisions about prescribing end-of-life anticipatory medications: a qualitative study. Ben Bowers, Sam S Barclay, Kristian Pollock and Stephen Barclay https://bjgp.org/content/70/699/e731

Anticipatory prescribing in community end-of-life care in the UK and Ireland during the COVID-19 pandemic: online survey. Bárbara Antunes, Ben Bowers, Isaac Winterburn, Michael P Kelly, Robert Brodrick, Kristian Pollock, Megha Majumder, Anna Spathis, Iain Lawrie, Rob George, Richella Ryan and Stephen Barclay https://spcare.bmj.com/content/10/3/343

Anticipatory prescribing of injectable medications for adults at the end of life in the community: A systematic literature review and narrative synthesis. Ben Bowers, Richella Ryan, Isla Kuhn, Stephen Barclay. https://journals.sagepub.com/doi/10.1177/0269216318815796

Administration of end-of-life drugs by family caregivers during covid-19 pandemic. Ben Bowers, Kristian Pollock, Stephen Barclay. https://doi.org/10.1136/bmj.m1615

National Guidance links:

  • https://www.nice.org.uk/guidance/NG31
  • https://www.bma.org.uk/advice-and-support/gp-practices/prescribing/anticipatory-prescribing-for-end-of-life-care
  • https://www.palliativecareguidelines.scot.nhs.uk/guidelines/pain/anticipatory-prescribing.aspx

Funders:

  • National Institute for Health Research (NIHR) Applied Research Collaboration East of England (ARC EoE) programme
  • National Institute for Health Research (NIHR) School for Primary Care Research
  • RCN Foundation
  • Abbeyfield Research Foundation

The views expressed are those of the author(s) and not necessarily those of the NIHR or the Department of Health and Social Care.

Credits:

Created with images by D_Van_Rensburg - "hands old age" • sabinevanerp - "book people adult"