Anticipatory Medications Research Articles

General practice utilisation by Australian cancer patients in the last year of life.

General practice plays a key role in end-of-life care, yet the extent of this remains largely unknown due to a lack of detailed clinical data. This study aims to describe the care provided by General Practitioners (GPs) for people with cancer in their last year of life. Retrospective cohort study using linked routine primary care and death certificate data in Victoria, Australia. Patients were included who died from cancer between 2008 and 2017. In total 7025 cancer patients were included, mean age of 74.8 yrs. 95% of patients visited their GP in the last 6 months of life, with a median of 11 general practice contacts in this period. 72% of patients visited their GP in the second-last month prior to death, and 74% in the last month of life. The majority of patients (58%) were prescribed opioids, 19% anticipatory medications, 24% received a home visit, and a small proportion had imaging (6%) in the last month and pathology (6%) in the last fortnight. Patients in regional areas had more contact with general practices in the last year of life compared to metropolitan patients (median metropolitan = 16, inner regional = 25, and outer regional = 23, P < .001). The use of GP services did not differ by cancer type. GP's play a central role in end-of-life care provision for cancer patients, which intensifies in the last months of life. There is room for improvement, with a proportion having little or no engagement, and low rates of home visits and anticipatory medication prescribing.

Generating Consensus on Good Practices in the Care of Portuguese Internal Medicine Patients Facing Imminent Death: A Delphi Study

Context: Modern medicine aims to ensure a world in which all people experience a good end of life as an integral part of their life journey. A good end-of-life experience means dying with dignity and receiving the best healthcare based on scientific evidence. Objective: This study aims to reach a consensus about the contents of a comprehensive instrument based on the 10/40 Model of the International Collaborative for the Best Care for the Dying Person for evaluating inpatients facing imminent death in Portuguese internal medicine wards and a proposal for anticipatory medication for symptom control in inpatient and home care settings. Methods: We employed the Delphi method and conducted various rounds of questionnaire administration to 23 Portuguese internists competent in palliative medicine. Data were obtained in July and September of 2022. Results: Consensus was reached among the expert panel on the diagnostic, initial assessment, monitoring, and after-death care items of the tool, with minor adjustments to wording or content. However, it was not possible to reach a consensus on most of the proposals presented for anticipatory medication for symptomatic control. Conclusion: We present the consensus about the contents of a comprehensive instrument for evaluating inpatients facing imminent death in Portuguese internal medicine wards. Best practices in this setting were defined from the point of view of internists with expertise in palliative care. However, the best pharmacological practices still require further reviews of the literature and consensus.

End Of Life Care in Nursing Home Residents Supported Through a Nursing Home Specialist Liaison Service

Abstract Background Advance Care Planning (ACP) is a crucial aspect of ensuring that nursing home residents receive care aligned with their preferences and values, especially as they approach the end of life. Supportive end of life care planning involves discussion with the person and/or their support person, symptom management and multidisciplinary collaboration. Evidence shows that even where an ACP has been recorded there can be significant barriers to enabling end of life care in the nursing home. We examined the role of a nursing home specialist liaison team in supporting implementation of ACPs towards end of life. Methods Retrospective analysis of medical and nursing care records from deceased residents referred to the liaison service in 2023 across four nursing homes in the hospital catchment was examined. Data included recording and/or reviewing of ACP at time of liaison consultation, anticipatory medication prescribing, cause and location of death. Results 41 resident reviews conducted by Registered Advanced Nurse Practitioner and/or Consultant Geriatrician. 16 (39%) of residents had an ACP in place at the time of initial review. 18 (26%) residents had anticipatory medications prescribed prior to liaison service consultation. Following consultation ACP documentation in residents increased to n=40 (97%). A further 11 (26%) residents were charted anticipatory medications at time of review as they were actively dying. Five (12%) residents required referral to specialist palliative care services for complex symptom management. All 41 residents passed away in the nursing home. Cardiac related issue was documented in 63% of reviews as cause of death. Conclusion Documentation of ACPs was low in this cohort of nursing home residents towards end of life. Input from the nursing home liaison service supported resident’s end of life care through consultation, support with ACP and anticipatory medication prescribing.

Differences in prescribing and dispensing at end-of-life between people who died at home before and during the Covid-19 pandemic in Scotland.

ObjectivesTo compare levels of palliative care need that were met through prescriptions and dispensing of medicines at end-of-life for people who died at home in Scotland during and prior to the Covid-19 pandemic. ApproachRetrospective observational study of linked routinely collected data: death registrations in Scotland during 12-month pandemic period (starting 23rd March 2020) and pre-pandemic period (5 years prior), linked to inpatient hospital admissions and community prescribing &amp; dispensing data. Prescribing/dispensing will be summarised for pandemic &amp; pre-pandemic cohorts and palliative care needs estimated using death registrations and inpatient admissions. ResultsAn estimated N=59,152 individuals died with palliative care needs during the first year of the pandemic, or approximately 11% more than in 2019/20. Community prescribing &amp; dispensing will be compared between the pandemic and pre-pandemic periods as a proxy measure of primary care use and to investigate shortages. Anticipatory medication use will be compared to estimate quality of death at home for decedents. ConclusionsDeaths at home increased by about a third during the first year of the pandemic in Scotland and continue at similar levels currently. Understanding the effect of the pandemic on prescriptions and dispensing at end-of-life will help explain the shift of deaths to home settings in addition to demographic and service contact changes early in the pandemic. ImplicationsStudying the changes in end-of-life medication use will inform policy to better continue supporting people dying at home, especially where there are unmet needs or gaps between prescribed and dispensed medications.

Primary care usage at the end of life: a retrospective cohort study of cancer patients using linked primary and hospital care data

PurposeHealth service use is most intensive in the final year of a person’s life, with 80% of this expenditure occurring in hospital. Close involvement of primary care services has been promoted to enhance quality end-of-life care that is appropriate to the needs of patients. However, the relationship between primary care involvement and patients’ use of hospital care is not well described. This study aims to examine primary care use in the last year of life for cancer patients and its relationship to hospital usage.MethodsRetrospective cohort study in Victoria, Australia, using linked routine care data from primary care, hospital and death certificates. Patients were included who died related to cancer between 2008 and 2017.ResultsA total of 758 patients were included, of whom 88% (n = 667) visited primary care during the last 6 months (median 9.1 consultations). In the last month of life, 45% of patients were prescribed opioids, and 3% had imaging requested. Patients who received home visits (13%) or anticipatory medications (15%) had less than half the median bed days in the last 3 months (4 vs 9 days, p < 0.001, 5 vs 10 days, p = 0.001) and 1 month of life (0 vs 2 days, p = 0.002, 0 vs 3 days, p < 0.001), and reduced emergency department presentations (32% vs 46%, p = 0.006, 31% vs 47% p < 0.001) in the final month.ConclusionThis study identifies two important primary care processes—home visits and anticipatory medication—associated with reduced hospital usage and intervention at the end of life.

A Microfluidic System for Investigating Anticipatory Medication Effects on Dopamine Homeostasis in Dopaminergic Cells.

Dopamine (DA) homeostasis influences emotions, neural circuit development, cognition, and the reward system. Dysfunctions in DA regulation can lead to neurological disorders, including depression, developmental disorders, and addiction. DA homeostasis disruption is a primary cause of Parkinson's Disease (PD). Therefore, understanding the relationship between DA homeostasis and PD progression may clarify the mechanisms for pharmacologically treating PD. This study developed a novel in vitro DA homeostasis platform which consists of three main parts: (1) a microfluidic device for culturing DAergic neurons, (2) an optical detection system for reading DA levels, and (3) an automatic closed-loop control system that establishes when and how much medication to infuse; this uses a microfluidic device that can cultivate DAergic neurons, perfuse solutions, perform in vitro PD modeling, and continuously monitor DA concentrations. The automatically controlled closed-loop control system simultaneously monitors pharmacological PD treatment to support long-term monitoring of DA homeostasis. SH-SY5Y neuroblastoma cells were chosen as DAergic neurons. They were cultivated in the microfluidic device, and real-time cellular DA level measurements successfully achieved long-term monitoring and modulation of DA homeostasis. When applied in combination with multiday cell culture, this advanced system can be used for drug screening and fundamental biological studies.

Simultaneously reassuring and unsettling: a longitudinal qualitative study of community anticipatory medication prescribing for older patients

The prescription of injectable anticipatory medications is widely accepted by clinicians to be key in facilitating effective last-days-of-life symptom control. Community end-of-life care and admission avoidance is particularly strongly advocated for older patients. However, patient and informal caregiver views and experiences of anticipatory medication have been little studied to date. To understand older patients', informal caregivers' and clinicians' views and experiences of the prescribing and use of anticipatory medications. Qualitative study. Patients' homes and residential care homes. Purposive sample of six older patients, nine informal caregivers and six clinicians. Multi-perspective, longitudinal interview study based on 11 patient cases. Semi-structured interviews (n = 28) were analysed thematically. Three themes were identified: (i) living in the present whilst making plans: anticipatory medications were used by clinicians as a practical tool in planning for uncertainty, while patients and informal caregivers tried to concentrate on living in the present; (ii) anticipation of dying: it was rare for patients and informal caregivers to discuss explicitly the process and experience of dying with clinicians; and (iii) accessing timely care: the use of anticipatory medications generally helped symptom control. However, informal caregivers reported difficulties in persuading nurses to administer them to patients. Anticipatory medications are simultaneously reassuring and a source of unease to older patients and their informal caregivers. Prescriptions need careful discussion and tailoring to their preferences and experience. Nurses' decisions to administer medication should consider informal caregivers' insights into patient distress, especially when patients can no longer communicate their needs.

OA20 Pneumatosis intestinalis with spontaneous pneumoperitoneum in a patient with systemic sclerosis-myositis overlap syndrome: a case report and review of the literature

OA20 Pneumatosis intestinalis with spontaneous pneumoperitoneum in a patient with systemic sclerosis-myositis overlap syndrome: a case report and review of the literature

Which patients received a ReSPECT form, what was documented and what were the patient outcomes? A protocol for a retrospective observational study investigating the impact of the COVID-19 pandemic on the implementation of the ReSPECT process

IntroductionRecommended Summary Plan for Emergency Care and Treatment (ReSPECT) is a UK advance care planning (ACP) initiative aiming to standardise the process of creating personalised recommendations for a person’s clinical...

Yonder: Anticipatory medications, food insecurity, childhood vaccination, and street sex workers.

Yonder: Anticipatory medications, food insecurity, childhood vaccination, and street sex workers.

Unwelcome memento mori or best clinical practice? Community end of life anticipatory medication prescribing practice: A mixed methods observational study

Background: Anticipatory medications are injectable drugs prescribed ahead of possible need for administration if distressing symptoms arise in the final days of life. Little is known about how they are prescribed in primary care. Aim: To investigate the frequency, timing and recorded circumstances of anticipatory medications prescribing for patients living at home and in residential care. Design: Retrospective mixed methods observational study using General Practitioner and community nursing clinical records. Setting/participants: 329 deceased adult patients registered with Eleven General Practitioner practices and two associated community nursing services in two English counties (30 most recent deaths per practice). Patients died from any cause except trauma, sudden death or suicide, between 4 March 2017 and 25 September 2019. Results: Anticipatory medications were prescribed for 167/329 (50.8%) of the deceased patients, between 0 and 1212 days before death (median 17 days). The likelihood of prescribing was significantly higher for patients with a recorded preferred place of death (odds ratio [OR] 34; 95% CI 15–77; p < 0.001) and specialist palliative care involvement (OR 7; 95% CI 3–19; p < 0.001). For 66.5% of patients (111/167) anticipatory medications were recorded as being prescribed as part of a single end-of-life planning intervention. Conclusion: The variability in the timing of prescriptions highlights the challenges in diagnosing the end-of-life phase and the potential risks of prescribing far in advance of possible need. Patient and family views and experiences of anticipatory medication care, and their preferences for involvement in prescribing decision-making, warrant urgent investigation.

Idiopathic Parkinson's Disease at the End of Life: A Retrospective Evaluation of Symptom Prevalence, Pharmacological Symptom Management and Transdermal Rotigotine Dosing.

Distressing symptoms are prevalent in patients with idiopathic Parkinson's disease, yet little is known about symptom burden and subsequent pharmacological management at the end of life. Additionally, when oral administration of antiparkinsonian medications is no longer possible in dying patients, it is becoming common place to initiate transdermal rotigotine, despite a paucity of evidence to guide dosing. To assess: (1) symptom prevalence from the use of anticipatory medicines in patients with idiopathic Parkinson's disease, (2) the prescribing of antiparkinsonian medication at the end of life; and (3) the accuracy of conversion from oral antiparkinsonian medicines to transdermal rotigotine and any associations between rotigotine dosing and end-of-life symptoms. A retrospective case review was performed. One hundred consecutive patients with idiopathic Parkinson's disease who died during an inpatient admission at a UK teaching hospital were assessed. The most prevalent terminal symptoms were excess respiratory secretions (58%), pain (52%), agitation (51%) and fever (23%). The majority of patients were converted to transdermal rotigotine (90%). Patients converted to a higher than equivalent dose of rotigotine were more likely to be agitated (p<0.05), whilst those converted to a lower than equivalent dose were less likely to develop excess respiratory secretions (p<0.05). The prevalence of pain did not differ according to rotigotine dosing. This study highlights for the first time use of anticipatory medications at the end of life in patients with idiopathic Parkinson's disease and the prevalence of terminal symptoms. It also demonstrates the widespread use of rotigotine patches, and that lower than equivalent doses may be better tolerated.

Modelling palliative and end-of-life resource requirements during COVID-19: implications for quality care

ObjectivesThe WHO estimates that the COVID-19 pandemic has led to more than 1.3 million deaths (1 377 395) globally (as of November 2020). This surge in death necessitates identification of...

129 “Pop-Up” Specialist End of Life Ward For COVID-19—The Nottingham Experience

BackgroundOur hospital trust anticipated an increased need for palliation and end of life care (EoLC) in patients with Covid-19 who were not appropriate for escalation and mechanical ventilation.InterventionA dedicated ward was opened as part of the trust-wide Covid-19 admissions pathway, led by geriatricians with palliative care input and staffed by relocated nursing and auxiliary personnel. Retrospective data was collected for consecutive patients admitted to the ward between 3rd April and 26th May 2020 and qualitative data regarding staff experience using a questionnaire.ResultOf the 168 patients (55% male) admitted, 31.5% came directly from Emergency Department, 17.3% from admission areas and the remainder from inpatient wards. Time spent on the ward ranged from 10 minutes to 17 days (median length of stay 43 hours). 75% had Clinical Frailty Scale score of 6 or more. 150 died with 75% naming Covid-19 as primary cause or contributing factor. Ward staff, who were not palliative care specialists, reported increased confidence in many aspects of palliation including assessing comfort, relieving symptoms, prescribing and administering anticipatory medications and in supporting and communicating with relatives. Staff apprehension about working on a Covid ward eased once the ward was established. Qualitative themes emerging from staff feedback included: professional competency, communication, prioritisation, team work, emotional response, care and consistency in a time of change.DiscussionThe pathway and referral system ensured that our ward cared for appropriate older patients living with frailty. The formation of a specialist unit over a short period of time created a series of logistical and management challenges. The emotional burden felt by staff was also prominent in feedback. These challenges were outweighed by the personal and professional development of staff coupled with the strong sense of teamwork, pride and enthusiasm felt in providing high quality care.

Mapping end-of-life and anticipatory medications in palliative care patients using a longitudinal general practice database.

End-of-life and anticipatory medications (AMs) have been widely used in various health care settings for people approaching end-of-life. Lack of access to medications at times of need may result in unnecessary hospital admissions and increased patient and family distress in managing palliative care at home. The study aimed to map the use of end-of-life and AM in a cohort of palliative care patients through the use of the Population Level Analysis and Reporting Data Space and to discuss the results through stakeholder consultation of the relevant organizations. A retrospective observational cohort study of 799 palliative care patients in 25 Australian general practice health records with a palliative care referral was undertaken over a period of 10 years. This was followed by stakeholders' consultation with palliative care nurse practitioners and general practitioners who have palliative care patients. End-of-life and AM prescribing have been increasing over the recent years. Only a small percentage (13.5%) of palliative care patients received medications through general practice. Stakeholders' consultation on AM prescribing showed that there is confusion about identifying patients needing medications for end-of-life and mixed knowledge about palliative care referral pathways. Improved knowledge and information around referral pathways enabling access to palliative care services for general practice patients and their caregivers are needed. Similarly, the increased utility of screening tools to identify patients with palliative care needs may be useful for health care practitioners to ensure timely care is provided.

Strengthening advance care planning in rural residential aged care through multidisciplinary educational case conferences: A hybrid implementation-effectiveness study

Strengthening advance care planning in residential aged care is now a priority. This hybrid implementation-effectiveness study aimed to implement and evaluate the effectiveness of multidisciplinary educational case conferences (MuDECC) in end-of-life planning in two Australian rural residential aged care facilities. MuDECCs are hour long meetings with the resident (where appropriate), their family/guardian and a multidisciplinary team of healthcare providers (including community pharmacists) to discuss and plan for the resident’s future end-of-life care needs. Between November 2018 and July 2019 ten MuDECCs were convened. The implementation was evaluated using a utilisation-focused approach. Intervention outcomes were documented advance care plans, availability of anticipatory end-of-life medications, and participant satisfaction. Of 23 persons who died during the study period, 65% had a documented end-of-life care plan; 57% had anticipatory medications charted. MuDECCs were reported to be acceptable, effective, and a valuable learning experience. By providing a framework for informed decision making and joint problem sharing, MuDECCs were effective in facilitating advance care planning and prescribing of anticipatory medications. However, MuDECCs were time consuming to organise with disproportionate responsibilities or time commitments borne by several key individuals. The necessary personal and professional capital to implement MuDECCs may be limited or unavailable in some rural locations.

Multicenter Evaluation of 434 Hospital Deaths From COVID-19: How Can We Improve End-of-Life Care During a Pandemic?

ContextThe pandemic has substantially increased the workload of hospital palliative care providers, requiring them to be responsive and innovative despite limited information on the specific end of life care needs of patients with COVID-19. Multi-site data detailing clinical characteristics of patient deaths from large populations, managed by specialist and generalist palliative care providers are lacking. ObjectivesTo conduct a large multicenter study examining characteristics of COVID-19 hospital deaths and implications for care. MethodsA multi-center retrospective evaluation examined 434 COVID-19 deaths in 5 hospital trusts over the period March 23, 2020 to May 10, 2020. ResultsEighty three percent of patients were over 70.32% were admitted from care homes. Diagnostic timing indicated over 90% of those who died contracted the virus in the community. Dying was recognized in over 90% of patients, with the possibility of dying being identified less than 48 hours from admission for a third. In over a quarter, death occurred less than 24 hours later. Patients who were recognized to be dying more than 72 hours prior to death were most likely to have access to medication for symptom control. ConclusionThis large multicenter study comprehensively describes COVID-19 deaths throughout the hospital setting. Clinicians are alert to and diagnose dying appropriately in most patients. Outcomes could be improved by advance care planning to establish preferences, including whether hospital admission is desirable, and alongside this, support the prompt use of anticipatory subcutaneous medications and syringe drivers if needed. Finally, rapid discharges and direct hospice admissions could better utilize hospice beds and improve care.

GPs' decisions about prescribing end-of-life anticipatory medications: a qualitative study.

BackgroundGPs have a central role in decisions about prescribing anticipatory medications to help control symptoms at the end of life. 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.AimTo explore GPs’ decision-making processes in the prescribing and use of anticipatory medications for patients at the end of life.Design and settingA qualitative interview study with GPs working in one English county.MethodSemi-structured interviews were conducted with a purposive sample of 13 GPs. Interview transcripts were analysed inductively using thematic analysis.ResultsThree themes were constructed from the data: something we can do, getting the timing right, and delegating care while retaining responsibility. Anticipatory medications were a tangible intervention GPs felt they could offer patients approaching death (something we can do). The prescribing of anticipatory medications was recognised as a harbinger of death for patients and their families. Nevertheless, GPs preferred to discuss and prescribe anticipatory medications weeks before death was expected whenever possible (getting the timing right). After prescribing medications, GPs relied on nurses to assess when to administer drugs and keep them updated about their use (delegating care while retaining responsibility).ConclusionGPs view anticipatory medications as key to symptom management for patients at the end of life. The drugs are often presented as a clinical recommendation to ensure patients and families accept the prescription. GPs need regular access to nurses and rely on their skills to administer drugs appropriately. Patients’ and families’ experiences of anticipatory medications, and their preferences for involvement in decision making, warrant urgent investigation.

Strategies to promote access to medications during the COVID-19 pandemic.

During the COVID-19 pandemic, vulnerable and older people with chronic and complex conditions have self-isolated in their homes, potentially limiting opportunities for consultations to have medications prescribed and dispensed. The aim of this article is to describe initiatives to ensure ongoing access tomedications during the COVID-19 pandemic. Cooperation between wholesalers and purchase limits in pharmacies have helped to ensure supply of essential medications. Therapeutic substitution by pharmacists is permitted for specific products authorised by the Therapeutic Goods Administration. Prescribers are permitted to issue digital image prescriptions, and implementation of electronic prescribing has been fast-tracked. Expanded continued dispensing arrangements introduced during the bushfire crises have been temporarily extended. Pharmacists are permitted to provide medication management reviews via telehealth. A Home Medicines Service has been introduced to facilitate delivery of medications to people who are vulnerable or elderly. Anticipatory prescribing and medication imprest systems are valuable for access to end-of-life medications within residential aged care.

Fentanyl Waste Was Reduced by Conservation Measures While Maintaining Patient Comfort During Moderate Sedation Endoscopy Procedures

Injectable fentanyl is widely used as part of moderate sedation for endoscopic procedures. In the setting of a national injectable fentanyl shortage, conservation measures were enacted in 4/2018 at our academic medical center, which performs over 14,000 moderate sedation endoscopy cases per year. We aimed to evaluate the impact of conservation measures on overall fentanyl use, fentanyl waste, and patient procedural tolerance. Conservation measures were implemented in the setting of increased awareness of fentanyl shortage (6 weeks after first hospital wide notifications). The measures consisted of: 1) education over a 1-week period on dose contained within each fentanyl ampule and change in recommended dose escalation strategy near threshold (100 mcg) and 2) nursing medication preparation protocol change to avoid anticipatory medication pre-draw. Data on procedural type, patient demographics, administered medication doses for fentanyl, midazolam, patient tolerance of procedure were retrospectively queried from our endoscopy reporting database for 6 months before and after implementation of above measures. Fentanyl waste data was queried for the same period from Omnicell® medication cabinet logs. Primary outcomes were average fentanyl dose administered, average fentanyl waste, and patient tolerance of procedure as documented by the provider. Statistical analyses were performed using Student’s t-test for continuous variables and Chi-squared test for categorical variables. 14,682 moderate sedation endoscopy cases (9,305 colonoscopies, 4,382 upper endoscopies, and 995 other) were performed in the 12-month period surrounding conservation measure implementation (7,393 pre, 7,289 post). A small but significant reduction in average fentanyl dose (106.9 mcg/case pre, 100.8 mcg/case post, p<0.0001) and a sizeable difference in average fentanyl waste (63.9 mcg/case pre, 48.9 mcg/case post, p<0.0001) (Figure 1) was observed after implementation of conservation measures without significant change in patient tolerance during endoscopy (“tolerated procedure well” 94.9% pre, 94.5% post, p = 0.4294). Total fentanyl ampules wasted in the 6 months pre and post-implementation decreased by 653 (5,680 to 5,027). Additionally, average midazolam dose also decreased during the same period (4.21 mg/case pre, 4.09 mg/case post, p<0.0001). Conscientious care in endoscopy using a low-cost, education/policy-based intervention in the setting of a fentanyl shortage is feasible with significant benefits. Conservation measures were highly effective in reducing fentanyl use and waste for moderate sedation endoscopic procedures without impacting patient experience.