Anticipatory prescribing enables prompt symptom relief at whatever time the patient develops distressing symptoms. Although each patient has individual needs, many acute events during the palliative period can be predicted, and management measures put in place.
'Just in case' boxes
Anticipatory prescribing:
ensures there is a supply of drugs in the patient’s home
ensure they have the apparatus needed to administer them
ensures both are available to an attending clinician for use where appropriate
these drugs belong to the patient, and have the same legal status as other prescribed controlled drugs.
In certain situations, it might be appropriate for drugs to be prescribed for use by the patient’s family with clear instructions. These supplies are normally provided in a specially marked ‘just in case’ box.
Nurse prescribers can provide them too. However, many GPs find that supplying these medications creates an opportunity to discuss with the patient and family their hopes and fears about the coming weeks.
Best practice
The health professional authorising administration of a pre-supplied anticipatory drug must accept responsibility for that decision.
The availability of such medication in the patient’s home is in no way a substitute for proper clinical evaluation at the time of a change in the patient’s condition.
The list of usual anticipatory drugs supplied should be agreed locally, with input from the LMC (local medical committee), other lead GPs, and specialist palliative care professionals such as the local hospice and community specialist palliative care teams.
Blanket prescribing of the same medications for all patients is discouraged – the ‘just in case’ box should be based on the individual patient’s underlying condition.
The normal starting doses should be agreed and available printed to minimise the chance of prescribing error.
The quantity supplied needs to be balanced between adequate supply and waste.
As a minimum, ‘just in case’ boxes should contain the anticipated drugs, administration equipment, written instructions as to dose and indications, and a way to keep a record.
The prescriber needs to be satisfied that the patient and carers understand the reasons for the medications. This is a good time to discuss the prognosis with the patient and their family, and to ensure they understand how to access care if their health deteriorates.
The out-of-hours service, and all others involved in the patient’s care, must be made aware of the clinical situation and the availability of drugs.
In Birmingham and Solihull patients clinically requiring anticipatory medication, who are being discharged from secondary care should be prescribed and discharged with 2 weeks of anticipatory medication.
A list of community pharmacies which are able to dispense anticipatory medication can be found here.
In exceptional circumstances, for community patients requiring anticipatory medication to be prescribed and dispensed out of hours, UHB pharmacy will be able to dispense EoL medication as per the Specialist Palliative Care Drug (SPCD) list. Please note that UHB Pharmacy is unable to routinely dispense prescriptions issued by a GP and would therefore be unable to dispense medicines whilst the SPCD cover is in operation, i.e. community pharmacy provision is available.
This means: the UHB Pharmacy route only becomes an option in the following circumstances:
- The medication need transpires between 12am and 8am (weekdays) or at weekends where there is no SPCD cover,
AND
(2) the patient would otherwise be admitted into hospital.
The hospital on call pharmacist can be paged via the UHB main switchboard 0121 3712000 / 0121 627 2000, the prescribing clinicians should ask for the on-call pharmacist, explain the medication required in end of life circumstances and who will be collecting the prescription.
Useful documents
NEW Form for Authorising Medicines in Symptom Control/End of Life for Patients needing Palliative Care Support.
From Sept 2021 there has been a slow introduction of a new form to replace previous forms in use e.g. yellow card – this is called the MASC (medicines authorisation for symptom control) form.
Why did it have to change?
Back in 2018, the Area Prescribing Committee recognised that across BSOL and Sandwell there were multiple forms in use. These varied from being extremely prescriptive with pre-printed doses through to blank forms that had been poorly photocopied over time. It was difficult for hospital trusts and hospices to discharge patients into community with the “correct” form for the area or team and there were incidents relating to unfamiliarity with forms or refusal to use certain forms and then a delay for the patient to be able to receive symptom control.
Aim: One form that could be used in any healthcare setting across the BSol APC area.
So who was on the group?
We sought input from all teams and all professionals involved to have a say in the form, and to be the liaison between their healthcare setting and the working group when it came to implementation.
Why did it take so long to develop?
Involving so many different teams, settings, and experiences and then having to adopt national recommendations e.g. post Gosport, takes time.
We started with an initial 16 page document which included everything people wanted. We then worked with colleagues to break this down to a practical form which would enable essential information to be documented and enable the authorisation of medications for administration.
Why are the drugs and doses not pre-printed?
This is following recommendations from Gosport with the need to have individualised plans for patients, not a “one size fits all”