11 How is anticipatory prescribing in community end of life care governed in the UK? A content analysis of national and local guidance documents

Abstract

Introduction Anticipatory prescribing (AP) in end of life care is a complex process consisting of at least 5 sequential phases: 1) decision to prescribe, 2) prescribing and dispensing, 3) set-up, storage and monitoring, 4) assessment and administration, and 5) post-death procedures. Little is known about how this process is governed across the UK. We aimed to investigate the scope and content of UK AP governance documents. Methods Stakeholders from a stratified random sample of 55 CCG areas in England and all health board (or equivalent) areas of Scotland (n=14), Wales (n=7) and Northern Ireland (n=5) were asked to supply their AP governance documents. Qualitative and quantitative content analysis was conducted using the 5 phases of AP as an analytical framework. A typology of approach to AP governance was developed. Results 49 sets of documents, 5 national (representing all 4 countries) and 44 local (33 English, 11 Scottish) were analysed. Two predominant types of approaches to AP governance were identified. Type 1 ‘Last Days of Life Care’: AP guidance is embedded within ‘last days of life’ symptom management guidelines and is usually limited to the prescribing and administration phases (predominant in England and NI). Type 2 ‘Anticipatory Care’: AP guidance covers more than the ‘last days of life’ period and documents specifically address all 5 phases of the AP process (predominant in Scotland). National frameworks supporting both approaches exist in Wales. Significant guidance gaps were identified with the type 1 approach, particularly in relation to: 1) timing of the decision to prescribe, 2) transition from prescription to administration, and 3) drug disposal. Conclusions Despite its complexity, AP is often treated as a simple component of ‘last days of life care’ within governance documents, resulting in important guidance gaps. National guidance development work is underway to address these gaps.