Carer administration of as-needed subcutaneous medication for breakthrough symptoms in people dying at home: the CARiAD feasibility RCT

Developing feasible person-centred care alternatives to emergency department responses for adults with epilepsy: a discrete choice analysis mixed-methods study

Background

Calls have been made for paramedics to have some form of care pathway that they could use to safely divert adults with epilepsy away from emergency departments and instigate ambulatory care improvements. Different configurations are possible. To know which to prioritise for implementation/evaluation, there is a need to determine which are acceptable to service users and likely National Health Service-feasible.

Objective(s)

(1) Identify configurations being considered, (2) understand service users' views of them and current provision, (3) identify what sort of care service users want and (4) determine which configuration(s) is considered to achieve optimal balance in meeting users' preference and being National Health Service-feasible.

Design

Service providers were surveyed to address objective 1. Interviews with service users addressed objective 2. Objective 3 was addressed by completing discrete choice experiments. These determined users' care preferences for different seizure scenarios. Objective 4 was addressed by completing 'knowledge exchange' workshops. At these, stakeholders considered the findings on users' stated preferences and judged different pathway configurations against Michie's 'acceptability, practicability, effectiveness, affordability, side-effects and equity' feasibility criteria.

Setting

This project took place in England. The survey recruited representatives from neurology and neuroscience centres and from urgent and emergency care providers. For the interviews, recruitment occurred via third-sector support groups. Recruitment for discrete choice experiments occurred via the North West Ambulance Service NHS Trust and public advert. Workshop participants were recruited from neurology and neuroscience centres, urgent and emergency care providers, support groups and commissioning networks.

Participants

Seventy-two services completed the survey. Interviews were conducted with 25 adults with epilepsy (and 5 relatives) who had emergency service contact in the prior 12 months. Discrete choice experiments were completed by 427 adults with epilepsy (and 167 relatives) who had ambulance service contact in the prior 12 months. Workshops were completed with 27 stakeholders.

Results

The survey identified a range of pathway configurations. They differed in where they would take the patient and their potential to instigate ambulatory care improvements. Users had been rarely consulted in designing them. The discrete choice experiments found that users want a configuration of care markedly different to that offered. Across the seizure scenarios, users wanted their paramedic to have access to their medical records; for an epilepsy specialist (e.g. an epilepsy nurse, neurologist) to be available to advise; for their general practitioner to receive a report; for the incident to generate an appointment with an epilepsy specialist; for the care episode to last < 6 hours; and there was a pattern of preference to avoid conveyance to emergency departments and stay where they were. Stakeholders judged this configuration to be National Health Service-feasible within 5-10 years, with some elements being immediately deployable.

Limitations

The discrete choice experiment sample was broadly representative, but those reporting recent contact with an epilepsy specialist were over-represented.

Conclusions

Users state they want a configuration of care that is markedly different to current provision. The configuration they prefer was, with support and investment, judged to likely be National Health Service-feasible. The preferred configuration should now be developed and evaluated to determine its actual deliverability and efficacy.

Study registration

The study is registered as researchregistry4723.

Funding

This award was funded by the National Institute for Health and Care Research (NIHR) Health and Social Care Delivery Research programme (NIHR award ref: 17/05/62) and is published in full in Health and Social Care Delivery Research; Vol. 12, No. 24. See the NIHR Funding and Awards website for further award information.

Administering injectable medications prescribed in the anticipation of the end of life in the community: A mixed-methods observational study

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.

Anticipatory prescribing in community end-of-life care: systematic review and narrative synthesis of the evidence since 2017

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.

The financial costs of anticipatory prescribing: A retrospective observational study of prescribed, administered and wasted medications using community clinical records

BACKGROUND

The prescribing of injectable end-of-life anticipatory medications ahead of possible need is recommended best practice. The financial costs of these medications have been little studied.

AIM

To identify the costs of anticipatory medications prescribed, used and not used for patients approaching the end-of-life at home and in residential care.

DESIGN

Retrospective observational study using general practitioner and community nursing clinical records.

SETTING/PARTICIPANTS

Data were collected from eleven general practitioner practices using the records of the 30 most recent deaths per practice. Patients were aged 18+ and died between 2017 and 2019 from any cause except trauma, sudden death or suicide.

RESULTS

Anticipatory medications were prescribed to 167/329 patients, of which 164 were included in the analysis. Costs (GBP) were analysed both at patient-level and drug-level. Median anticipatory prescription cost was £43.17 (IQR: £38.98-£60.47, range £8.76-£229.82). Median administered (used) drug cost was £2.16 (IQR: £0.00-£12.09, range £0.00-£83.14). Median unused (wasted) drug cost was £41.47 (IQR: £29.15-£54.33, range £0.00-£195.36). Prescription, administered and unused costs were significantly higher for the 59 patients prescribed an anticipatory syringe driver. There were wide variations in the unused costs of individual drugs; Haloperidol and Cyclizine contributed 49% of total unused costs.

CONCLUSION

The costs of prescribed and unused anticipatory medications were higher than previously reported but remain modest. Usage of prescriptions was lower than previously documented. There may be scope to reduce the quantity of vials that are routinely prescribed without adversely affecting care; further research is needed to investigate this possibility.

An evaluation of an online education programme to improve nurses' ability to support carers to use subcutaneous medicines

BACKGROUND

Most Australians say they wish to die at home, but many are admitted to inpatient facilities for symptom management. Caring@home resources can be used to support informal carers to manage breakthrough symptoms safely using subcutaneous medicines. Nurses require education about how to teach informal carers to use these resources.

AIM

To evaluate the effectiveness and relevance of an online education programme for registered nurses (RNs) about using the caring@home resources.

METHODS

Nurses must complete an online survey prior to the commencement of the online education programme and again upon completion to assess their change in skills, knowledge, confidence and attitudes of the RNs. T-tests were conducted to compare average pre- and post-education scores.

FINDINGS

The knowledge, skills and confidence of RNs to teach carers improved significantly following the completion of an education programme. There was a significant change in attitude, meaning that the perceived benefit of teaching informal carers to give subcutaneous medicines improved. All reported they would use the resources in their clinical practice.

CONCLUSION

The online education programme is an effective and cost-efficient strategy to educate nurses to support informal carers to help manage breakthrough symptoms using subcutaneous medicines.

Family carers' administration of injectable medications at the end of life: a service evaluation of a novel intervention

Timely and safe administration of injectable medications for patients at home is vital in optimally managing distressing symptoms in the final days of life. This article discusses a service evaluation of family carers' (including close friends) administrating subcutaneous end-of-life medications. The procedure was not intended to become normal care, rather the exception when appropriate and needed, with 24/7 skilled support from community nursing and palliative care services. A service evaluation of the procedure was undertaken in rural and urban areas in the South East of England. The procedure ran over 6 months and used detailed processes with recruitment criteria to mitigate risk of harm. In total, 11 patients participated with their family carers, including five carers with experience in healthcare roles. Of the 11 family carers, 10 were able to administer injections safely with structured training and support in place. Patients received timely symptom relief and their family carers were able to support loved ones by administering injectable medications rapidly without waiting for a nurse to arrive. This was particularly welcomed in more rural areas where waiting times were greater due to the large geographical area covered and limited staff availability during out-of-hours periods. The findings informed a carefully monitored wider rollout and ongoing evaluation in adult community nursing services in the NHS Trust.

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

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.

Caregiver Burden Correlates With Complexity of Drug Regimen in Non-oncological Palliative Medicine

BACKGROUND

Progressive chronic diseases presume a complex treatment plan that depends on the number of symptoms, their severity, and comorbidities. Drug management is an essential responsibility of the family caregiver of a palliative care patient, but has received limited attention in field research.

STUDY QUESTIONS

The aim of this study is to identify the complexity of the therapeutic plan followed at home by cancer or noncancer patients needing palliative care, and to assess its impact on the burden of the family caregivers.

STUDY DESIGN

This observational study was conducted at patient's admission in a palliative care department. The study involved cancer and noncancer patients and their primary family caregivers. To measure the care burden, the Burden Scale for Family Caregiver was used and for the complexity of the therapeutic plan, the Medication Regime Complexity Index.

MEASURES AND OUTCOMES

To measure the care burden, the Burden Scale for Family Caregiver was used and for the complexity of the therapeutic plan, the Medication Regime Complexity Index.

RESULTS

One hundred and forty patients were enrolled with their family caregivers: patients with nononcological pathologies (n = 63) and patients with cancer (n = 77). Caregiver's burden score is statistically significantly correlated with the complexity of the medical plan in both groups (P = 0.32 and P = 0.012 respectively). The average family caregiver's burden was significantly higher in the nononcological group (45 ± 14.45 vs. 36.52 ± 15.05; P = 0.001). The number of medications that family caregivers administer daily for patients without cancer is higher than in the other subset (8.25 ± 4.94 vs. 5.89 ± 4.93; P = 0.004). Opioids were more frequently used for pain control in cancer patients (5 vs. 72; P = 0.0001).

CONCLUSIONS

The caregiver's burden is high for nononcological patients. The complexity of the treatment plan (number of drugs and frequency of administration) is significantly correlated with the care burden. Further studies are needed to understand which interventions targeted on family caregivers will minimize the burden of care.

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

OBJECTIVES

The 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 resource needs and relies on modelling resource and understanding anticipated surges in demand. Our aim was to develop a generic computer model that could estimate resources required for end-of-life (EoL) care delivery during the pandemic.

SETTING

A discrete event simulation model was developed and used to estimate resourcing needs for a geographical area in the South West of England. While our analysis focused on the UK setting, the model is flexible to changes in demand and setting.

PARTICIPANTS

We used the model to estimate resourcing needs for a population of around 1 million people.

PRIMARY AND SECONDARY OUTCOME MEASURES

The model predicts the per-day 'staff' and 'stuff' resourcing required to meet a given level of incoming EoL care activity.

RESULTS

A mean of 11.97 hours of additional community nurse time, up to 33 hours of care assistant time and up to 30 hours additional care from care assistant night sits will be required per day as a result of out of hospital COVID-19 deaths based on the model prediction. Specialist palliative care demand is predicted to increase up to 19 hours per day. An additional 286 anticipatory medicine bundles per month will be necessary to alleviate physical symptoms at the EoL care for patients with COVID-19: an average additional 10.21 bundles of anticipatory medication per day. An average additional 9.35 syringe pumps could be needed to be in use per day.

CONCLUSIONS

The analysis for a large region in the South West of England shows the significant additional physical and human resource required to relieve suffering at the EoL as part of a pandemic response.