49 Understanding current practice in prescribing and using anticipatory medicines at the end of life

Abstract

Background Anticipatory medications (AMs) are injectable drugs prescribed to a named patient, ahead of likely clinical need, for administration by visiting General Practitioners (GPs) and Community Nurses if symptoms arise in the final days of life. While the prescribing of AMs is recommended best practice in the UK, little is known about how they are used in primary care. Aim To investigate primary care practice in issuing and using AMs for patients approaching the end of life. Methods Retrospective review of the GP and Community Nursing records of 240 sequential patient deaths in eight GP practices in two UK counties (30 deaths per practice). Analysis used descriptive statistics and constant comparison between patient cases. Results 132/240 (55%) of deceased patients were issued AMs, between 695 and 0 days before death (median 17 days across all eight practices, range of median 38 days to 6 days in individual GP practices). AMs were often issued alongside completion of a DNACPR form: documented discussions centred on patients expressing preferences to stay at home and avoid hospital admission. 79/132 (60%) of the patients issued AMs went on to have them administered, almost exclusively by Community Nurses. Drugs were first used between 586 and 0 days before death (median 3 days). AMs were typically used when patients were identified as dying and unable to swallow oral medications. However, for 10/79 (13%) of patient where AMs were used, they were started more than 2 months before death for reversible conditions and/or not at the end of life. Conclusions The issuing and use of AMs were commonplace in all the GP practices, with considerable variation in timing between GP practices and community nursing teams. The findings highlight the challenges in diagnosing dying and the risks involved in prescribing AMs far in advance of likely need.