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Bowers B, Pollock K, Wilkerson I, Massou E, Brimicombe J, Barclay S. Administering injectable medications prescribed in the anticipation of the end of life in the community: A mixed-methods observational study. Int J Nurs Stud 2024; 153:104734. [PMID: 38762308 DOI: 10.1016/j.ijnurstu.2024.104734] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2023] [Revised: 02/22/2024] [Accepted: 02/23/2024] [Indexed: 05/20/2024]
Abstract
BACKGROUND The prescription of injectable anticipatory medications ahead of possible need for last-days-of-life symptom relief is established community practice internationally. Healthcare teams and policy makers view anticipatory medication as having a key role in optimising effective and timely symptom control. However, how these medications are subsequently administered (used) is unclear and warrants detailed investigation to inform interdisciplinary practice and guidance. OBJECTIVE To identify the frequency, timing and recorded circumstances of the administration of injectable end-of-life anticipatory medications prescribed for patients living at home and in residential care. DESIGN A retrospective mixed-methods observational study using general practitioner (family doctor) and community nursing held clinical records. SETTING(S) Community-based care in two English counties. PARTICIPANTS 167 deceased adult patients (aged 18+) registered with eleven general practitioner practices and two associated community nursing services. These were patients prescribed anticipatory medications, identified from the 30 most recent deaths per practice. Patients died between 1 March 2017 and 25 September 2019, from any cause except trauma, sudden death or suicide. METHODS Patient characteristics, anticipatory medication discussions, recorded administration contexts and decision-making, medication details, recorded symptom control and comfort at death were collected from clinical records. Data analysis combined quantitative and qualitative analyses in a mixed methods approach. RESULTS Anticipatory medications were administered to 59.9 % (100/167) patients, commenced between 0 and 586 days before death (median 3 days). Their usage was similar for patients who died from cancer and non-cancer conditions. Anticipatory medications were almost universally started and titrated by visiting nurses. Eleven patients had medications started between 59 days and 586 days before death for recorded reversible non-end-of-life care conditions. Only 5 % (5/100) of patient records contained detailed accounts of patient participation in decisions to start medications: four were recorded as being reluctant to commence medications but agreed to trial injections to relieve symptoms. Crucially, there was recurrent under-recording of the effectiveness of injectable medications and patient comfort. CONCLUSIONS Prescribed medications were commonly administered by visiting community nurses to help manage last-days-of-life symptoms. However, patient records infrequently referred to the effectiveness of administered medication and perceived patient comfort. Most recorded references to patient and family preferences for involvement in anticipatory medication decision-making and their experiences of care were brief and perfunctory. More detailed information should be routinely recorded in clinical records to enable assessment of the appropriate and effective use of anticipatory medicines and how inter-professional collaboration and services could be developed to provide adequate twenty-four-hour cover. TWEETABLE ABSTRACT Effectiveness of injectable end-of-life symptom control medications and patient comfort often under-recorded @Ben_Bowers__ @PELi_Cam @TheQNI.
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Affiliation(s)
- Ben Bowers
- Department of Public Health and Primary Care, University of Cambridge, Cambridge, United Kingdom; Queen's Nursing Institute, London, United Kingdom; Nottingham Centre for the Advancement of Research into Supportive, Palliative and End-of-Life Care, School of Health Sciences, University of Nottingham, United Kingdom; Cambridgeshire and Peterborough NHS Foundation Trust, Cambridge, United Kingdom.
| | - Kristian Pollock
- Nottingham Centre for the Advancement of Research into Supportive, Palliative and End-of-Life Care, School of Health Sciences, University of Nottingham, United Kingdom
| | - Isobel Wilkerson
- Cambridgeshire and Peterborough NHS Foundation Trust, Cambridge, United Kingdom
| | - Efthalia Massou
- Department of Public Health and Primary Care, University of Cambridge, Cambridge, United Kingdom
| | - James Brimicombe
- Department of Public Health and Primary Care, University of Cambridge, Cambridge, United Kingdom
| | - Stephen Barclay
- Department of Public Health and Primary Care, University of Cambridge, Cambridge, United Kingdom; Cambridgeshire and Peterborough NHS Foundation Trust, Cambridge, United Kingdom
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Teggi D, Woodthorpe K. Anticipatory prescribing of injectable controlled drugs (ICDs) in care homes: a qualitative observational study of staff role, uncertain dying and hospital transfer at the end-of-life. BMC Geriatr 2024; 24:310. [PMID: 38570758 PMCID: PMC10988888 DOI: 10.1186/s12877-024-04801-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2023] [Accepted: 02/10/2024] [Indexed: 04/05/2024] Open
Abstract
BACKGROUND The anticipatory prescribing of injectable controlled drugs (ICDs) by general practitioners (GPs) to care home residents is common practice and is believed to reduce emergency hospital transfers at the end-of-life. However, evidence about the process of ICD prescribing and how it affects residents' hospital transfer is limited. The study examined how care home nurses and senior carers (senior staff) describe their role in ICDs prescribing and identify that role to affect residents' hospital transfers at the end-of-life. METHODS 1,440 h of participant observation in five care homes in England between May 2019 and March 2020. Semi-structured interviews with a range of staff. Interviews (n = 25) and fieldnotes (2,761 handwritten A5 pages) were analysed thematically. RESULTS Senior staff request GPs to prescribe ICDs ahead of residents' expected death and review prescribed ICDs for as long as residents survive. Senior staff use this mechanism to ascertain the clinical appropriateness of withholding potentially life-extending emergency care (which usually led to hospital transfer) and demonstrate safe care provision to GPs certifying the medical cause of death. This enables senior staff to facilitate a care home death for residents experiencing uncertain dying trajectories. CONCLUSION Senior staff use GPs' prescriptions and reviews of ICDs to pre-empt hospital transfers at the end-of-life. Policy should indicate a clear timeframe for ICD review to make hospital transfer avoidance less reliant on trust between senior staff and GPs. The timeframe should match the period before death allowing GPs to certify death without triggering a Coroner's referral.
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Affiliation(s)
- Diana Teggi
- Department of Social and Policy Sciences, Centre for Death and Society (CDAS), University of Bath, Bath, UK.
| | - Kate Woodthorpe
- Department of Social and Policy Sciences, Centre for Death and Society (CDAS), University of Bath, Bath, UK.
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Bowers B, Antunes BCP, Etkind S, Hopkins SA, Winterburn I, Kuhn I, Pollock K, Barclay S. Anticipatory prescribing in community end-of-life care: systematic review and narrative synthesis of the evidence since 2017. BMJ Support Palliat Care 2024; 13:e612-e623. [PMID: 37236648 PMCID: PMC10850730 DOI: 10.1136/spcare-2022-004080] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2022] [Accepted: 04/15/2023] [Indexed: 05/28/2023]
Abstract
BACKGROUND The anticipatory prescribing of injectable medications is recommended practice in controlling distressing symptoms in the last days of life. A 2017 systematic review found practice and guidance was based on inadequate evidence. Since then, there has been considerable additional research, warranting a new review. AIM To review the evidence published since 2017 concerning anticipatory prescribing of injectable medications for adults at the end-of-life in the community, to inform practice and guidance. DESIGN Systematic review and narrative synthesis. METHODS Nine literature databases were searched from May 2017 to March 2022, alongside reference, citation and journal hand-searches. Gough's Weight of Evidence framework was used to appraise included studies. RESULTS Twenty-eight papers were included in the synthesis. Evidence published since 2017 shows that standardised prescribing of four medications for anticipated symptoms is commonplace in the UK; evidence of practices in other countries is limited. There is limited data on how often medications are administered in the community. Prescriptions are 'accepted' by family caregivers despite inadequate explanations and they generally appreciate having access to medications. Robust evidence of the clinical and cost-effectiveness of anticipatory prescribing remains absent. CONCLUSION The evidence underpinning anticipatory prescribing practice and policy remains based primarily on healthcare professionals' perceptions that the intervention is reassuring, provides effective, timely symptom relief in the community and prevents crisis hospital admissions. There is still inadequate evidence regarding optimal medications and dose ranges, and the effectiveness of these prescriptions. Patient and family caregiver experiences of anticipatory prescriptions warrant urgent investigation. PROSPERO REGISTRATION CRD42016052108.
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Affiliation(s)
- Ben Bowers
- Department of Public Health and Primary Care, University of Cambridge, Cambridge, Cambridgeshire, UK
- Queen's Nursing Institute, London, UK
| | | | - Simon Etkind
- Department of Public Health and Primary Care, University of Cambridge, Cambridge, Cambridgeshire, UK
| | - Sarah A Hopkins
- Department of Public Health and Primary Care, University of Cambridge, Cambridge, Cambridgeshire, UK
| | - Isaac Winterburn
- Department of Psychiatry, Cambridge University, Cambridge, Cambridgeshire, UK
| | - Isla Kuhn
- School of Clinical Medicine, Cambridge University, Cambridge, Cambridgeshire, UK
| | - Kristian Pollock
- School of Health Sciences, University of Nottingham, Nottingham, UK
| | - Stephen Barclay
- Department of Public Health and Primary Care, University of Cambridge, Cambridge, Cambridgeshire, UK
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Bowers B, Howard P, Madden B, Pollock K, Barclay S. Is end-of-life anticipatory prescribing always enough? BMJ 2023; 381:1106. [PMID: 37192773 DOI: 10.1136/bmj.p1106] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/18/2023]
Affiliation(s)
- Ben Bowers
- Primary Care Unit, Department of Public Health and Primary Care, University of Cambridge, UK
- Nottingham Centre for the Advancement of Research into Supportive, Palliative, and End of Life Care, School of Health Sciences, University of Nottingham, UK
| | - Paul Howard
- Mountbatten Hospice and St Mary's Hospice, Isle of Wight, UK
| | - Bella Madden
- Primary Care Unit, Department of Public Health and Primary Care, University of Cambridge, UK
| | - Kristian Pollock
- Nottingham Centre for the Advancement of Research into Supportive, Palliative, and End of Life Care, School of Health Sciences, University of Nottingham, UK
| | - Stephen Barclay
- Primary Care Unit, Department of Public Health and Primary Care, University of Cambridge, UK
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Sharp WS, Svynarenko R, Fornehed MLC, Cozad MJ, Malpass JK, Mack JW, Hinds PS, Mooney-Doyle K, Mendola A, Lindley LC. Conceptualizing the Value of Pediatric Concurrent Hospice Care. J Hosp Palliat Nurs 2023; 25:31-38. [PMID: 36289556 PMCID: PMC9839492 DOI: 10.1097/njh.0000000000000918] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
Given that pediatric concurrent hospice care has been available for more than a decade, it is appropriate to seek an understanding of the value of this care delivery approach. Value is the cost associated with achieving beneficial health outcomes. In pursuit of this goal, the current literature on pediatric concurrent hospice care was synthesized and used to develop a model to explain its value. Because of its relevance, the Value Assessment Framework was used to conceptualize the value of pediatric concurrent hospice care. This framework gauges the value of a health care service through 2 components: long-term effect and short-term affordability. The framework considers comparative clinical effectiveness, cost-effectiveness, other benefits or disadvantages, contextual considerations, and potential budget impact. Evidence from the literature suggested that the value of concurrent care depended on clinical outcomes evaluated, costs examined, medical services used, care coordinated, context considered, and budget impacted. The literature demonstrated that pediatric concurrent hospice care does offer significant value for children and their families. The conceptual model highlighted the need for a comprehensive approach to assessing value. The model is a useful framework for future research examining the value of concurrent hospice care.
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Affiliation(s)
| | | | | | | | | | | | - Pamela S. Hinds
- Children's National Hospital, School of Medicine and Health Sciences
| | | | - Annette Mendola
- Department of Medicine, University of Tennessee Medical Center
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Bowers B, Pollock K, Barclay S. Simultaneously reassuring and unsettling: a longitudinal qualitative study of community anticipatory medication prescribing for older patients. Age Ageing 2022; 51:6881500. [PMID: 36477784 PMCID: PMC9729004 DOI: 10.1093/ageing/afac293] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2022] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND 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. OBJECTIVE To understand older patients', informal caregivers' and clinicians' views and experiences of the prescribing and use of anticipatory medications. DESIGN Qualitative study. SETTING Patients' homes and residential care homes. PARTICIPANTS Purposive sample of six older patients, nine informal caregivers and six clinicians. METHODS Multi-perspective, longitudinal interview study based on 11 patient cases. Semi-structured interviews (n = 28) were analysed thematically. RESULTS 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. CONCLUSIONS 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.
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Affiliation(s)
- Ben Bowers
- Address correspondence to: Ben Bowers, Primary Care Unit, Department of Public Health and Primary Care, University of Cambridge, East Forvie Building, Robinson Way, Cambridge CB2 0SR, UK. Tel: +44 1223 763082. E-mail:
| | - Kristian Pollock
- Nottingham Centre for the Advancement of Research into Supportive, Palliative and End of Life Care, School of Health Sciences, University of Nottingham, Nottingham NG8 1BB, UK
| | - Stephen Barclay
- Palliative & End of Life Care Group in Cambridge (PELiCAM), Primary Care Unit, Department of Public Health and Primary Care, University of Cambridge, Cambridge CB2 0SR, UK
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Roberts B, Robertson M, Ojukwu EI, Wu DS. Home Based Palliative Care: Known Benefits and Future Directions. CURRENT GERIATRICS REPORTS 2021; 10:141-147. [PMID: 34849331 PMCID: PMC8614075 DOI: 10.1007/s13670-021-00372-8] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/14/2021] [Indexed: 11/23/2022]
Abstract
Purpose of Review To summarize key recent evidence regarding the impact of Home-Based Palliative Care (HBPalC) and to highlight opportunities for future study. Recent Findings HBPalC is cost effective and benefits patients and caregivers across the health care continuum. Summary High-quality data support the cost effectiveness of HBPalC. A growing literature base supports the benefits of HBPalC for patients, families, and informal caregivers by alleviating symptoms, reducing unwanted hospitalizations, and offering support at the end of life. Numerous innovative HBPalC models exist, but there is a lack of high-quality evidence comparing specific models across subpopulations. Our wide literature search captured no research regarding HBPalC for underserved populations. Further research will also be necessary to guide quality standards for HBPalC.
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Affiliation(s)
- Benjamin Roberts
- Department of Medicine, Johns Hopkins Bayview Medical Center, Johns Hopkins University School of Medicine, Baltimore, MD USA
| | - Mariah Robertson
- Division of Geriatric Medicine and Gerontology, Johns Hopkins University School of Medicine, Baltimore, MD USA
| | - Ekene I Ojukwu
- Department of Medicine, Johns Hopkins Bayview Medical Center, Johns Hopkins University School of Medicine, Baltimore, MD USA
| | - David Shih Wu
- Department of Medicine, Johns Hopkins Bayview Medical Center, Johns Hopkins University School of Medicine, Baltimore, MD USA
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Impact of palliative care on end-of-life care and place of death in children, adolescents, and young adults with life-limiting conditions: A systematic review. Palliat Support Care 2021; 19:488-500. [PMID: 33478607 DOI: 10.1017/s1478951520001455] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
OBJECTIVE To determine the impact of palliative care (PC) on end-of-life (EoL) care and the place of death (PoD) in children, adolescents, and young adults with life-limiting conditions. METHOD Eight online databases (PubMed, Medline, EMBASE, Cochrane Library, CINAHL, Airiti, GARUDA Garba Rujukan Digital, and OpenGrey) from 2010 to February 5, 2020 were searched for studies investigating EoL care and the PoD for pediatric patients receiving and not receiving PC. RESULTS Of the 6,468 citations identified, 14 cohort studies and one case series were included. An evidence base of mainly adequate- and strong-quality studies shows that inpatient hospital PC, either with or without the provision of home and community PC, was found to be associated with a decrease in intensive care use and high-intensity EoL care. Conflicting evidence was found for the association between PC and hospital admissions, length of stay in hospital, resuscitation at the time of death, and the proportion of hospital and home deaths. SIGNIFICANCE OF RESULTS Current evidence suggests that specialist, multidisciplinary involvement, and continuity of PC are required to reduce the intensity of EoL care. Careful attention should be paid to the need for a longer length of stay in a medical setting late in life, and earlier EoL care discussion should take place with patients/caregivers, especially in regard to attempting resuscitation in toddlers, adolescents, and the young adult population. A lack of robust evidence has identified a gap in rigorous multisite prospective studies utilizing data collection.
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Archibald N, Bakal JA, Richman-Eisenstat J, Kalluri M. Early Integrated Palliative Care Bundle Impacts Location of Death in Interstitial Lung Disease: A Pilot Retrospective Study. Am J Hosp Palliat Care 2020; 38:104-113. [PMID: 32431183 DOI: 10.1177/1049909120924995] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023] Open
Abstract
BACKGROUND Interstitial lung diseases (ILDs) comprise a heterogeneous group of fibrotic, progressive pulmonary diseases characterized by poor end-of-life care and hospital deaths. In 2012, we launched our Multidisciplinary Collaborative (MDC) ILD clinic to deliver integrated palliative approach throughout disease trajectory to improve care. We sought to explore the effects of palliative care and other factors on location of death (LOD) of patients with ILD. METHODS The MDC-ILD clinic implemented a palliative care bundle including advance care planning (ACP), opiates use, allied health home care engagement, and use of supplemental oxygen and early caregiver engagement in care. Data from patients with ILD who attended the clinic and died between 2012 and 2019 were used to generate scores representing the components and duration of palliative care (palliative care bundle score) and caregiver involvement (caregiver engagement score). We examined the impact of these scores on patients' LOD. RESULTS A total of 92 MDC-ILD clinic patients were included, 57 (62%) had home or hospice deaths. Patients who died at home or hospice had higher palliative care bundle scores (10.0 ± 4.0 vs 7.8 ± 3.9, P = .01) and caregiver engagement scores (1.7 ± 0.6 vs 1.3 ± 0.7, P = .01) compared to those who died in hospital. Patients were 1.13 times more likely to die at home or hospice following a 1-point increase in palliative care bundle score (95% CI: 1.01-1.29, P = .04) and 2.38 times more likely following a 1-point increase in caregiver engagement score (95% CI: 1.17-5.15, P = .02). CONCLUSIONS Home and hospice deaths are feasible in ILD. Early initiation of palliative care bundle components such as ACP discussions, symptom self-management, caregiver engagement, and close collaboration with allied health home care supports can promote adherence to patient preference for home or hospice deaths.
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Affiliation(s)
- Nathan Archibald
- Department of Physiology, 98623University of Alberta, Edmonton, Alberta, Canada
| | - Jeffrey A Bakal
- Provincial Research Data Services, 3146Alberta Health Services, Edmonton, Alberta, Canada
| | - Janice Richman-Eisenstat
- Division of Pulmonary Medicine, Department of Medicine, 12357University of Alberta, Edmonton, Alberta, Canada.,3146Alberta Health Services, Edmonton, Alberta, Canada
| | - Meena Kalluri
- Division of Pulmonary Medicine, Department of Medicine, 12357University of Alberta, Edmonton, Alberta, Canada.,3146Alberta Health Services, Edmonton, Alberta, Canada
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