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The Hillingdon Macmillan Community Palliative Care Team (HPCT) has been using anticipatory medication prescribing as part of its advanced care planning process since 2006.
The team carried out an audit of its process for the first time last year and results show that anticipatory medication significantly improves the chance of people dying in their preferred place of care. The audit found that over 90% of patients were able to die in their preferred place of care having had anticipatory medication prescribed, compared to 55% who didn’t.
The team set out to identify:
- the average length of time from patient referral to the team to time of death
- the time between obtaining anticipatory medication to the death of the patient
- the current practice pattern in relation to how the anticipatory medication is organised.
The audit explored the outcome and usage of anticipatory prescribing for people in palliative care in the community over a six-month period. It also explored the correlation between the provision of anticipatory medication and preferred place of care. Finally, we compared the ordered medications with their actual use.
All patients under the team’s care during the audit period were included.
The audit involved data collection by clinical nurse specialists, who completed a survey on each death/discharge of patient within their caseload for six months. One hundred and forty-one audit forms were returned representing 65% of total number of deaths (n=218) during the audit period.
Nearly 80% of patients in the audit had been prescribed anticipatory medication. The audit found that patients didn’t get the medication too early, which had previously been raised as a concern. On average, patients were given the anticipatory medication during the last 10 weeks of their lives, where symptoms would occur due to their deteriorating physical condition.
Over 70% of the anticipatory medication was organised and prescribed by primary health care team using the Gold Standard Framework| (GSF). 24% was prescribed by hospital team. This figure covers patients who were discharged to a nursing home placement for end-of-life care.
Morphine sulphate, cyclizine, midazolam and glycopyrronium were the most frequently prescribed medications, in line with local guidelines. Of these, midazolam was the most used drug from the medication pack, followed by morphine sulphate.
The audit identified good practice - the involvement of primary healthcare team using the GSF. However, it touched on safety issues, such as the need for better record keeping and multi-prescribing.
The results of the audit were presented to the end-of-life forum group and fed back to clinical governance team. Anticipatory medication documentation has since been renewed. The results will also be shared with the medicine management team to inform prescribers. It would be useful to repeat the audit in the district nursing teams in future.
1. Nursing Home Project (Hillingdon Community Health)
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