Enhancing Anticipatory Prescribing in End of Life Care Research Led by Ben Bowers, Kristian Pollock, Louisa Polak and Stephen Barclay.

What is anticipatory prescribing?

Anticipatory Prescribing is the prescription and dispensing of injectable medications to a named patient, ahead of possible need, for use if symptoms arise in the final days of life. Medications are typically prescribed for symptoms of pain, nausea and vomiting, agitation, and respiratory secretions. The intervention seeks to improve symptom control at home and reduce crisis hospital admissions.

Anticipatory Prescribing is considered to be an important intervention in supporting patients and families who wish to have last days of life care at home. Once prescribed, the medications are kept in the home (or care home) and typically are used by visiting doctors or nurses if the patient is dying and requires symptom relief.

The challenge

The Covid-19 pandemic has accelerated the practice of Anticipatory Prescribing; more terminally ill patients are having end-of-life care at home and in care homes. This upward trend of deaths in community settings will continue in coming years, as the population ages and more people die from chronic life limiting conditions. Although Anticipatory Prescribing is recommended practice in the UK, and a number of other countries, the evidence base to support this common practice is unclear.

A review of the anticipatory prescribing evidence-base

Relevance of the research

The Anticipatory Prescribing of injectable medications to provide end-of-life symptom relief is an established community practice in a number of countries. The knowledge base to support this practice is unclear. The researchers carried out a systematic literature review and narrative synthesis to clarify the current knowledge base and the priority areas for future research.

Significance of the research

The Independent Review of the Liverpool Care Pathway found that the use of Anticipatory Prescribing without adequate explanation or justification led to families being concerned about over-sedation and the medication hastening death. Despite these concerns, subsequent National Institute for Health and Care Excellence (NICE) end-of-life care guidance continues to advocate “individualised” Anticipatory Prescribing as best practice. However, the same guidance highlighted the limited evidence base concerning Anticipatory Prescribing practice, and the risk that medications are sometimes prescribed in a ‘blanket-like fashion’ rather than tailored to patients’ needs.

In summary, it is unclear whether anticipatory prescribing is acceptable to all involved, clinically effective or cost-effective.

The research

Methods: The review search identified 5099 titles, with 34 papers included in the synthesis.

Key findings: Healthcare professionals believe anticipatory prescribing provides reassurance, effective symptom control, and helps to prevent crisis hospital admissions. The attitudes of patients towards anticipatory prescribing remain unknown. Anticipatory prescribing is a low-cost intervention. There is inadequate evidence to allow conclusions to be drawn about its cost-effectiveness, safety, impact on patient-reported symptoms, and comfort or prevention of crisis hospital admissions.

The outcomes

Anticipatory prescribing is recommended and widespread practice in many countries, despite an inadequate knowledge base. Policy and practice are running ahead of the evidence, based largely on the belief of healthcare professionals that it reassures patients and their family carers, effectively controls symptoms and prevents crisis hospital admissions.

The views and experiences of patients and their family carers towards anticipatory prescribing need urgent investigation. Further research is needed to investigate the impact of anticipatory prescribing on patients’ symptoms and comfort, patient safety, and hospital admissions.

Bowers B, Ryan R, Kuhn I, Barclay S (2019) Anticipatory prescribing of injectable medications for adults at the end of life in the community: A systematic literature review and narrative synthesis. Palliative Medicine 33(2): 160-177.

Read the paper: https://doi.org/10.1177/0269216318815796

An updated review of the anticipatory prescribing evidence published since 2017

Relevance of research

Our 2017 systematic review found practice and guidance was based on inadequate evidence. Since then, there has been considerable additional research, warranting a new review to determine how knowledge has advanced.

Significance

Our previous review and synthesis of the published evidence found anticipatory prescribing was based primarily on the belief of doctors and nurses that access to these medications reassures patients and their families and helps ensure timely symptom relief. There was inadequate evidence to allow conclusions to be drawn about anticipatory prescribing in terms of its cost-effectiveness, safety, impact on patient-reported symptoms, or prevention of crisis hospital admissions. No studies had examined patient views and experiences of anticipatory prescribing.

In summary, there was a lack of high-quality research to inform care.

The research

Design: Systematic review and narrative synthesis.

Methods: The updated review search found 2397 titles published between May 2017 to March 2022, with 28 papers included in the new synthesis.

Key findings: 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. Only one small study has directly investigated the experiences or views of patients. The prescribing of anticipatory medications appears to be a significant event for patients and signifies the imminence of death. 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.

The outcomes

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 limited evidence concerning likely symptom profiles and which medications and dose ranges are needed. The views and experiences of patients and their family caregivers towards anticipatory prescribing need further investigation. Urgent research is necessary to investigate the clinical effectiveness, cost-effectiveness, safety and acceptability of different anticipatory prescribing practices.

Bowers B, Antunes BCP, Etkind S, Hopkins S, 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 Supportive & Palliative Care 2023.

Read the paper: https://doi.org/10.1136/spcare-2022-004080

Changes in anticipatory prescribing practices during Covid-19

Relevance of research

Anticipatory prescribing seeks to optimise end-of-life symptom control in community settings. The number of people dying in care homes and at home has risen dramatically during the COVID-19 pandemic in the UK and other countries. Anticipatory prescribing guidance and practice has changed in response. The evidence base for current anticipatory prescribing practice is sparse, so learning about the changes in practice during the pandemic is critical.

Significance

The end of life is an extremely important phase of life for patients, families, close friends and healthcare providers. Anticipatory prescribing is considered a key intervention in enabling optimal symptom control if it is aligned with patients’ and families wishes. We need to ensure anticipatory prescribing is done safely, with low risks for all involved and in a way that will contribute for patient and families’ well-being throughout the end-of-life journey.

The outcomes

This study revealed rapid changes in anticipatory prescribing practice was underway and under consideration in many areas of the UK and Ireland. Clinicians were considering increasing the use of alternative medications to address stock shortages, new routes of administration, family caregiver administration, or prescribing drugs closer to death and in smaller quantities. There were calls to revise pharmaceutical regulations to permit repurposing of anticipatory prescribing medications in care homes, wider community drug access, and recycling unused medications returned to pharmacies. Reflecting broader changes in clinical practice during the pandemic, more community end-of-life care medical consultations and anticipatory prescribing was being undertaken remotely, with increased 24 hours availability. These changes will potentially significantly affect care during the pandemic and in the future.

Antunes B, Bowers B, Winterburn I, Kelly MP, Brodrick R, Pollock K, Majumder M, Spathis A, Lawrie I, George R, Ryan R, Barclay S. (2020) Anticipatory prescribing in community end-of-life care in the UK and Ireland during the COVID-19 pandemic: online survey. BMJ Supportive & Palliative Care.

Read the paper: http://dx.doi.org/10.1136/bmjspcare-2020-002394

Community-based anticipatory prescribing during Covid-19: an interview study

Relevance of research

The Covid-19 pandemic led to increase in the number of deaths in the community and often a rapid rise in demand for community end-of-life care. Early on in the pandemic, healthcare professionals across the UK and Ireland described plans to modify their anticipatory prescribing practice to address possible medication and staff shortages. National guidance was rapidly produced about managing community deaths during the pandemic, exploring alternatives to injectable medication and supporting relatives to administer this medication.

The research

Design and setting: This descriptive qualitative study follows an online survey about AP undertaken in April 2020, near the start of the Covid-19 pandemic. Interviews were undertaken with healthcare professionals from range of professional groups and locations across the UK about their views and experiences of anticipatory prescribing.

Methods: Semi-structured qualitative interviews were conducted with a purposive sample of 16 healthcare professionals involved in community palliative care. Interview transcripts were analysed inductively using thematic analysis.

Key findings: Some of practitioners’ fears about the pandemic’s impact on delivering anticipatory prescribing had not been realised during the first wave. Among patients with Covid-19 for whom community end-of-life care was deemed appropriate, deaths were perceived to be relatively easy to palliate with standard medications. These deaths were typically too rapid for anticipatory prescribing to be appropriate or feasible.

For non-Covid deaths, providing timely anticipatory prescribing was more challenging. Although community nurses and some palliative specialists continued to visit patients regularly, general practitioners did many fewer visits, moving abruptly to mainly remote consultations. This left some community nurses feeling under-supported, and prompted some palliative specialists to increase their direct involvement in anticipatory prescribing.

Several other changes were widely welcomed: collaboration to maintain drug supplies, adoption of online meetings and paperless practice, enhanced specialist helplines and a new policy allowing reuse of medication in care homes. The inclusion of more non-injectable options in local anticipatory prescribing guidance allowed clinicians to offer selected patients more choice, but few had yet done this in practice. No participants reported changing their pre-pandemic practice regarding administration of anticipatory medications by family caregivers.

The outcomes

Accomplishing anticipatory prescribing during a pandemic was challenging, requiring healthcare professionals to make rapid changes to their systems and practices. This required them to attend to their prescription choices and to ‘stuff, staff and systems’. Some changes may produce lasting improvements. Understanding their experiences helps in identifying important questions for future research and in shaping the ongoing evolution of anticipatory prescribing practice in the UK and internationally.

Antunes B, Bowers B, Barclay S, Gallagher J, Conci R, Polak L. Community-based anticipatory prescribing during COVID-19: a qualitative study. BMJ Supportive & Palliative Care Online.

Read the paper: https://doi.org/10.1136/spcare-2021-003470

General Practitioners decisions about prescribing anticipatory medications

Relevance of research

The prescribing of anticipatory medications to provide symptom relief in last days of life care is recommended practice in the UK, Australia, and New Zealand. General Practitioners (GPs) have a central role in decisions about prescribing anticipatory medications to help control symptoms at the end of life. The GP remains accountable for the medications they have prescribed, including strong opioids, which may be in the home for weeks. Once prescribed, permission has been granted for nurses to use anticipatory medications based on their clinical assessment that the person is dying and has distressing symptoms.

The research

Design and setting: This interpretive descriptive study was conducted in an English county with a mixture of urban and rural communities. Interviews were undertaken with GPs from a range of practices about their views and experiences of decision-making about end-of-life anticipatory medications.

Methods: Semi-structured interviews were conducted with a purposive sample of 13 GPs in 2017. Interview transcripts were analysed inductively using thematic analysis.

Key findings: This study found that GPs are keen to prescribe anticipatory medications weeks ahead of death even if they are unlikely to be needed. Anticipatory medications were a tangible intervention GPs felt they could offer patients approaching death.

The prescribing of anticipatory medications was recognised as a harbinger of death for patients and their families. Nevertheless, most GPs preferred to discuss and prescribe anticipatory medications as early as was possible and clinically appropriate. GPs often recall framing anticipatory medications as their clinical recommendation to ensure that the prescription is accepted by patients and their families.

GPs were very aware that they remained responsible for anticipatory medications once prescribed. They had little knowledge or control over when they were used. They relied on nurses to assess when to administer medications and keep them updated about their use. Having easy access to nurses was perceived to be crucial in facilitating good end-of-life care and the appropriate use of anticipatory medications.

The outcomes

GPs view anticipatory medications as key to symptom management for patients at the end of life. The medications are often presented as a clinical recommendation to ensure patients and families accept the prescription. They need regular access to nurses and rely on their skills to administer medications appropriately. Patients’ and families’ experiences of anticipatory medications, and their preferences for involvement in decision making, warrant urgent investigation.

Bowers B, Barclay SS, Pollock K, Barclay S (2020) General Practitioners’ decisions about prescribing end-of-life anticipatory medications: a qualitative study. British Journal of General Practice; 70(699) e731-739.

Read the paper: https://doi.org/10.3399/bjgp20X712625

Unwelcome memento mori or best clinical practice?

Relevance of research

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.

The research

Design and setting: Retrospective mixed methods observational study using General Practitioner and community nursing clinical records in two English counties.

Methods: This mixed-methods study looked at the records of 329 deceased adult patients registered with eleven General Practitioner practices and two associated community nursing services (30 most recent deaths per practice). Patients died from any cause except trauma, sudden death or suicide. Quantitative and qualitative analysis were used to provide detailed and complementary insights into practice.

Key findings: Half (50.8%) of 329 patients whose deaths were potentially predictable deaths were prescribed anticipatory medications, the timing of prescriptions ranging from 0 to 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. Anticipatory medications were frequently prescribed as standardised drugs and doses, and often as part of a single end-of-life care planning intervention.

Patients’ and family caregivers’ involvement in prescribing decisions was unclear. Clinical records were largely silent about conversations with patients and family members concerning the implications and emotional impacts of anticipatory medication prescribing.

The outcomes

The variability in the timing of prescriptions, at times many months before death, highlights the challenges in diagnosing the end-of-life phase and the potential risks of prescribing far in advance of possible need. The presence of anticipatory medications for long periods of time, or when situations are uncertain, may therefore compromise patient safety unless robust systems are in place to review their continued appropriateness and safe use.

Patient and family views and experiences of anticipatory medication care, and their preferences for involvement in prescribing decision-making, warrant urgent investigation.

Bowers B, Pollock K, Barclay S. Unwelcome memento mori or best clinical practice? Community end-of-life anticipatory medication prescribing practice: a mixed methods observational study. Palliative Medicine 2022; 36(1): 95-10.

Read the paper: https://doi.org/10.1177/0269216321104338

Administering injectable medications prescribed in the anticipation of the end of life in the community

Relevance of research

How prescribed injectable end-of-life anticipatory medications are subsequently administered (used) is unclear and warrants detailed investigation to inform interdisciplinary practice and guidance.

The research

Design and setting: Retrospective mixed methods observational study using General Practitioner and community nursing held clinical records in two English counties.

Methods: This mixed-methods study looked at the records of 167 deceased adult patients 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 from any cause except trauma, sudden death or suicide. Data analysis combined quantitative and qualitative analyses in a mixed methods approach.

Key findings: Anticipatory medications were administered to 59 % (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.

The outcomes

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 the patient and family preferences for involvement in anticipatory medication decision-making and their experiences of care are brief and perfunctory.

More detailed information should be routinely recorded in clinical records to enable assessment of appropriate and effective use of anticipatory medicines and how inter-professional collaboration and services could be developed to provide adequate twenty-four-hour cover.

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. International Journal of Nursing Studies 2024. 153: 104734.

Read the paper: https://doi.org/10.1016/j.ijnurstu.2024.104734

Patients’ and family caregivers’ views and experiences of anticipatory medication care

Relevance of research

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 family caregiver views and experiences of anticipatory medication have been little studied to date.

The research

Design and setting: Qualitative research investigating the dying and anticipatory medication care of patients through a series of interviews with patients, their family caregivers and clinicians. Fieldwork was undertaken in two English counties with a mixture of urban and rural communities.

Methods: Semi-structured interviews were conducted based on eleven patient-centred cases in 2020. Six patients, nine family caregivers, three GPs and three nurses took part. In total, 28 interviews were carried out, including during the last days of life and bereavement. Interview transcripts were analysed inductively using thematic analysis.

Key findings: Anticipatory medications were simultaneously reassuring and unsettling. Most patients and family caregivers appreciated having injectable medications available in the home. But, for some, the medications were viewed as an unwelcome reminder of impending death at a time when they were trying to cope with ever-changing circumstances and maintain a sense of optimism.

Most of the patients and family caregivers did not recall having a detailed conversation about what they were for or how they could be used. So, some patients and caregivers did not understand the purpose of injectable medications or the practicalities of managing symptoms in the last days of life.

Participants had variable experiences of getting medications administered. Patients who could clearly express their preferences did not experience difficulties with nurses starting injections: their requests for medications were met swiftly. In contrast, five family caregivers said they had to convince nurses to start injectable medications after patients appeared to be in pain or distress.

The outcomes

These findings challenge the widespread perception that once anticipatory medications are available in homes, patients will receive timely and appropriate symptom control care.

The prescribing of anticipatory medications is a nuanced and complex intervention and requires tailored and honest discussion about dying, possible last-days-of-life symptoms and the medications. These conversations need revisiting as situations and preferences change.

Future research is needed to understand how complex, nuanced decisions to use medication can be made more inclusive and better incorporate patient and families experiences of illness and care. Nurses’ decisions to administer medications should take into consideration family caregivers’ insights into patient discomfort and distress, especially when individuals are no longer able to communicate their needs.

Bowers B, Pollock K, Barclay S (2022) Simultaneously reassuring and unsettling: a longitudinal qualitative study of community anticipatory medication prescribing for older patients. Age and Ageing; 51(12) afac293.

Read the paper: https://doi.org/10.1093/ageing/afac293

Image credit: Debra Graham

Anticipatory syringe pumps: benefits and risks

Relevance of research

In safe hands, syringe pumps facilitate appropriate and effective control of pain and other symptoms for patients who are no longer able to swallow or absorb oral medication, commonly at the end of life. The Gosport War Memorial Hospital Independent Inquiry has increased public and clinician awareness about syringe pumps (drivers) for continuous subcutaneous delivery of opioids and other medications at the end of life. The inquiry found that at least 456 patients died where opioids had been prescribed and administered in unjustified doses, commonly via syringe pumps. In an overstretched clinical climate in which clinicians are encouraged to plan ahead to optimise patient care, the Gosport inquiry is a timely warning of the potential dangers of ‘anticipatory syringe pumps’ prescribed in anticipation of future symptoms at the end of life.

The research

Immediately pre-COVID, the researchers completed a retrospective observational study of anticipatory medication practice in primary care. They reviewed 329 patient records from 11 General Practitioner (GP) practices (30 most recent predictable deaths per practice) in two English counties. Anticipatory syringe pumps were prescribed for 49/167 (29.3%) of patients issued with anticipatory medications, with considerable variation in frequency between GP practices, ranging from 10/14 patients (71.4%) to 1/16 patients (6.3%). Prescription timing varied from 536 to 0 days before death (median 5.5). There were notably diverse prescribing cultures: median time from prescription to death ranged from 27 to 2 days across individual GP practices.

A parallel research review of a random sample of 28 local community anticipatory prescribing policies and drug authorisation charts in England found explicit guidance regarding the appropriateness of anticipatory syringe pumps was in place in only 12 areas (paper in preparation). This suggests unregulated practice exists in some areas where anticipatory syringe pumps are used, without robust governance and documentation systems to support practice. There is a real risk of administration errors in the absence of reminders and checks to ensure oral medicines are stopped, and existing transdermal medicines are considered, when anticipatory syringe pumps are commenced.

The outcomes

There is a danger that specialist palliative care practice for patients with complex needs is being followed in General Practice for those with less complex symptom profiles. Concurring with the Association of Supportive and Palliative Care Pharmacy (ASPCP) recent position statement, the researchers recommend syringe pumps should only be prescribed after a face-to-face clinical review by a skilled prescriber to consider causes of deterioration and associated symptoms, evaluate reversibility, establish a dying diagnosis and appraise the effectiveness of previously administered oral and ‘as required’ (PRN) drug injections. In the relatively unusual circumstances in which an anticipatory syringe pump is appropriate, it is important to ensure that prescribers regularly reassess the patient’s needs and review the prescription accordingly.

Bowers B, Pollock K, Dickman A, Ryan R, Barclay S. Balancing the benefits and risks of anticipatory syringe pumps. BMJ Supportive & Palliative Care Published Online.

Read the paper: https://doi.org/10.1136/bmjspcare-2020-002735

Family caregivers’ administration of injectable medications: a service evaluation

Relevance of research

Timely and safe administration of injectable anticipatory medications for patients at home is vital in optimally managing distressing symptoms in the final days of life. To meet the need for effective 24-hour symptom control, a pilot procedure for family caregivers (including close friends) willing and able to take on the responsibility for giving ‘as required’ subcutaneous injectable medications to help control painful and distressing end-of-life symptoms was developed and implemented. This was intended to give family caregivers and healthcare teams a safe and supported framework to work within.

The service evaluation

Setting and design: The service evaluation was undertaken with community nursing teams in a 550 square mile area in a Community NHS Trust, working with two local hospices providing specialist palliative care and general practitioners. The service covered rural and urban areas in the South East of England. Quality improvement methods were used to understand the implementation and outcomes of the pilot procedure, identify opportunities for strengthening and monitoring patient safety measures.

Methods: The pilot procedure ran over six months and used detailed processes with recruitment criteria to minimise any potential harm. In total, 11 patients participated with their family caregivers, including five carers with experience in healthcare roles.

Key findings: Of the 11 family caregivers, 10 were able to administer injections safely with structured training and support in place. Patients received timely symptom relief and their family caregivers 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 outcomes

The successful pilot led to a wider expansion for the procedure in areas of the Community NHS Trust, supported by a palliative care telephone hub. Implementation of similar schemes requires investment in palliative and end-of-life care 24/7 clinician telephone advice and coordination hubs.

O’Hara L, Evans C, Bowers B. Family carers’ administration of injectable medications at the end of life: a service evaluation of a novel intervention. British Journal of Community Nursing 2023; 28(6).

Read the paper: https://doi.org/10.12968/bjcn.2023.28.6.284

The financial costs of anticipatory prescribing

Relevance of research

In the UK, at least half of community-based patients approaching the end of their lives are thought to receive prescriptions of anticipatory medications. International guidance recommends individualised prescribing based on a patient’s likely needs, but most patients receive a standardised prescription of four medications, to treat common symptoms that might arise in the last days of life: pain, shortness of breath, nausea and vomiting, agitation and noisy respiratory secretions. The financial costs of these medications have been little studied.

The research

Methods: An observational study of 164 deceased patients’ recorded care using general practitioner and community nursing electronic and paper clinical records. Examination of patient-level and drug-level prescribing, usage and wastage (unused) medication costs. Costs were analysed at both patient-level and drug-level.

Key findings: While 59% of the patients received some doses of medication, most of the medications in patients’ homes and care homes remained unused. In total, 85% of the prescription costs were spent on unused medications.

The cost per patient of the medications that were prescribed in advance of need ranged from £8.76 to £229.82, with a median of £43.17 per patient, higher than was previously thought. The median cost for the medications used per patient was just £2.16 while the median cost of the unused medications was £41.47 per patient.

Drugs for nausea and/or vomiting (often Haloperidol and Cyclizine) and noisy respiratory secretions (often Glycopyrronium Bromide) accounted for nearly two-thirds (64%) of total wastage costs.

The outcomes

Prescription and wastage costs are higher than previously estimated but remain modest. There may be scope to reduce the number of vials of Haloperidol, Cyclizine and Glycopyrronium prescribed if they are thought less likely to be needed. Prospective research with health economics components is needed to investigate this possibility and its implications for patient safety and effective, timely symptom control.

Morgan L, Barclay S, Pollock K, Massou E, Bowers B. The financial costs of anticipatory prescribing: A retrospective observational study of prescribed, administered and wasted medications using community clinical records. Palliative Medicine 2023. Online.

Read the paper: https://doi.org/10.1177/02692163231198372

Rethinking anticipatory prescribing: key messages from research

For the 51% of patients who die at home or in a care home in the UK, obtaining medical assessments, prescriptions and drugs from pharmacies during lengthy overnight and weekend hours can be challenging and at times impossible. Recognising the problem, National Institute for Health and Care Excellence (NICE) advises prescribing anticipatory medicines as ‘early as possible’ for people who are likely to need symptom control in the last days of life.

However, our research at the University of Cambridge shows that anticipatory prescribing (AP) does not always result in timely and effective control of symptoms. Read the full University of Cambridge Research Alert for more information.

Improving symptom control at the end of life: four areas for action

Overall, we suggest that there’s a strong case for change. Feedback from practitioners from across the UK supports this. We emphasise that anticipatory prescribing is a complex intervention and that making substantive improvements requires system-level changes. We propose the following four areas for action:

1. Responsive communication between families and healthcare professionals:

Anticipatory prescribing is an opportunity to hold open, tailored and honest conversations about patients’ and families’ concerns and the realities of dying, if they indicate that this is their preference, rather than being used as a clinical strategy to keep discussions vague.

2. Responding to changing clinical needs

Robust integrated systems such as record-sharing and interdisciplinary meetings are needed to ensure that medications and dose ranges are reviewed regularly and that they are administered when clinically appropriate.

3. Providing support 24/7

Patients and family caregivers need access to community nursing, community pharmacies and doctor services 24 hours a day, seven days a week.

4. Listening to the insights of families and carers

Community nurses and paramedics require consistent and comprehensive training in the recognition of, and appropriate responses to, end-of-life symptoms and the appropriate administration of anticipatory medications.

"This body of research clearly tells us that prescribing of anticipatory medications is not the simple ‘fix’ in controlling distressing symptoms that we as healthcare professionals often hope it to be. Anticipatory prescribing is a complex and sensitive intervention requiring careful thought, person-centred discussion and regular reviews, often across multiple community providers of care.”

Dr Ben Bowers, Primary Care Unit, University of Cambridge

End-of-life care websites

Anticipatory prescribing research papers

• Bowers B, Antunes BCP, Etkind S, Hopkins S, 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 Supportive & Palliative Care 2023. Online First: 26 May 2023. Systematic review of 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.
• O’Hara L, Evans C, Bowers B. Family carers’ administration of injectable medications at the end of life: a service evaluation of a novel intervention. British Journal of Community Nursing 2023; 28(6)
• Bowers B, Pollock K, Barclay S. Simultaneously reassuring and unsettling: a longitudinal qualitative study of community anticipatory medication prescribing for older patients. Age and Ageing 2022. 51(12): Online First. Longitudinal qualitative interview study investigating older patients’, informal caregivers’ and clinicians’ views and experiences of the prescribing and use of anticipatory medications.
• Bowers B, Pollock K, Barclay S. Unwelcome memento mori or best clinical practice? Community end-of-life anticipatory medication prescribing practice: a mixed methods observational study. Palliative Medicine 2022; 36(1): 95-10. Retrospective mixed methods observational study investigating the frequency, timing and recorded circumstances of anticipatory medications prescribing for patients living at home and in residential care.
• 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. International Journal of Nursing Studies 2024. 153: 104734.
• Majumder M, Bowers B, Pollock K, Goodman C, Kuhn I, Barclay S. End of life care in UK care homes – controlled drugs: systematic review and narrative synthesis. BMJ Supportive & Palliative Care Online First: 29 June 2022.
• Antunes B, Bowers B, Barclay S, Gallagher J, Conci R, Polak L. Community-based anticipatory prescribing during COVID-19: a qualitative study. BMJ Supportive & Palliative Care Online First: 1 June 2022. Qualitative interview study investigating healthcare professionals’ experiences of delivering anticipatory prescribing during the first wave of the UK COVID-19 pandemic.
• Bowers B, Barclay SS, Pollock K, Barclay S. General Practitioners’ decisions about prescribing end-of-life anticipatory medications: a qualitative study. British Journal of General Practice 2020; 70(699) e731-739. Qualitative interview study exploring GPs’ decision-making processes in the prescribing and use of anticipatory medications for patients at the end of life.
• Antunes B, Bowers B, Winterburn I, et al. Anticipatory prescribing in community end-of-life care in the UK and Ireland during the COVID-19 pandemic: online survey. BMJ Supportive & Palliative Care 2020; 10: 343-349. Online survey investigating UK and Ireland clinicians’ experiences concerning changes in anticipatory prescribing during the COVID-19 pandemic and their recommendations for change.
• Bowers B, Ryan R, Kuhn I, Barclay S. Anticipatory prescribing of injectable medications for adults at the end of life in the community: A systematic literature review and narrative synthesis. Palliative Medicine 2019; 33(2): 160-177. Systematic review of the published evidence concerning anticipatory prescribing of injectable medications for adults at the end of life in the community.
• Bowers B, Redsell S. A qualitative study of community nurses’ decision-making around the anticipatory prescribing of end-of-life medications. Journal of Advanced Nursing 2017; 73(10): 2385-2394. Qualitative interview study investigating community nurses’ decision-making processes around the prescribing of anticipatory medications for people who are dying.
• Morgan L, Barclay S, Pollock K, Massou E, Bowers B. The financial costs of anticipatory prescribing: A retrospective observational study of prescribed, administered and wasted medications using community clinical records. Palliative Medicine 2023. Online First: 10 October 2023

Evidence-based editorials

• Bowers B, Pollock K, Barclay S. Administration of end-of-life drugs by family caregivers during covid-19 pandemic. British Medical Journal 2020; 369: m1615
• Bowers B, Howard P, Madden B, Pollock K, Barclay S. Is end-of-life anticipatory prescribing always enough? British Medical Journal 2023; 381: p1106
• Bowers B, Wilson E. Managing medication at the end of life: supporting family carers. British Journal of Community Nursing 2023; 28(1):34-36
• Bowers B, Pollock K, Dickman A, Ryan R, Barclay S. Anticipatory syringe pumps: benefits and risks. BMJ Supportive & Palliative Care Published Online First: 19 January 2021

National Guidance links:

Funders:

• National Institute for Health Research (NIHR) Applied Research Collaboration East of England (ARC EoE) programme
• Wellcome Trust [Award: 225577/Z/22/Z]
• National Institute for Health Research (NIHR) School for Primary Care Research
• RCN Foundation
• Abbeyfield Research Foundation

This study/project is supported by the National Institute for Health and Care Research (NIHR) Applied Research Collaboration East of England (NIHR ARC EoE) at Cambridgeshire and Peterborough NHS Foundation Trust. The views expressed are those of the author(s) and not necessarily those of the NIHR or the Department of Health and Social Care.