HP Procedure for the Anticipatory Supply of Palliative Care Medications at End of Life
PROCEDURE: Procedure for the Anticipatory Supply of Palliative Care Medications at End of Life
NATURE AND SCOPE: Health Partnerships
SUBJECT: Procedure for the Anticipatory Supply of Palliative Care Medications at End of Life
DATE OF LATEST RATIFICATION: August 2014
RATIFIED BY:HP Medicines Management Group
IMPLEMENTATION DATE: September 2014
REVIEW DATE: August 2017
ASSOCIATED TRUST POLICIES
AND PROCEDURES:
NICE Guidance for Supportive & Palliative Care 2004
DH Delivering the Out-of-Hours Review 2004
NHS Gold Standards Framework Prognostic Indicators Guidance
Mental Capacity Act 2005
Health Partnerships Procedure for the
Anticipatory Supply of Palliative Care Medications
At End of Life
Reference / HP2014039Directorate / Health Partnerships
Document purpose / Improve access to palliative medications for adults at the end of life
Version / 1
Title / Health Partnerships Procedure for the Anticipatory Supply of Palliative Care Medications at End of Life
Author/Nominated Lead / Jane Swan, Senior Medicines Management Advisor, Health Partnerships
Approval Date / 19th August2014
Approving Committee / HP Medicines Management Group
Review Date / August 2017
Groups/staff Consulted / Specialist Palliative Care Service, Assistant Director of Nursing, Quality and Patient Experience, District Nursing Clinical Leads.
Target audience / Health Partnerships staff
Circulation list / Adult Community Nursing leads and Specialist Palliative Care Services
Associated documents / NICE Guidance for Supportive & Palliative Care 2004
DH Delivering the Out-of-Hours Review 2004
NHS Gold Standards Framework Prognostic Indicators Guidance
Mental Capacity Act 2005
Superseded documents / NCtPCT Policy for the Anticipatory Supply of Palliative Care Medications V1.2 May 2008 CLIN/POL/2009/210
Sponsoring Manager / Michelle Bateman, Associate Director, Nursing, Quality and Patient Experience
Contents
- Introduction
- Procedure Statement
- Equality Impact Assessment
- The Scheme
- Known Risks
- The Contents of the Palliative Care Pack
- The Process
- Collection and Delivery Arrangements
- Storage of the Medications
- Authorisation & Administration of Medication from the Palliative Care Pack
- Using the Palliative Care Pack
- Checking the Pack
- Discrepancies Found when Checking the Pack
- Information Sheets
- Pack No Longer Required
- Audit
County Health Partnerships:
Appendix 1 CHP DNS1 completed example
Appendix 2 CHP T34 Check list
Appendix 3 CHP - FP10 prescription completed example
Appendix 4 CHP Palliative Medication Care Packs Patient and Carer Information
Appendix 5 CHP Anticipatory Supply of Palliative Care Medications General Practitioner / Community Nurse Information
Bassetlaw Health Partnerships:
Appendix 6 BHP IPOC Drug Sheets
Appendix 7 BHP T34 Check list
Appendix 8 BHP - FP10 prescription completed example
Appendix 9 BHP Palliative Medication Care Packs Patient and Carer Information
Appendix 10 BHP Anticipatory Supply of Palliative Care Medications General Practitioner / Community Nurse Information
Procedure for the Anticipatory Supply of Palliative Medications at End of Life
1Introduction
1.1The Gold Standards Framework for Palliative Care is already widely in use across Nottinghamshire County. This framework helps to develop and implement a standard of quality care, including anticipatory prescribing for distressing symptoms.
1.2Despite the fact that up to 90% of all palliative care occurs in a patient’s home environment and the majority of patients and their carers wish for a home death, most people die in an institution. Uncontrolled symptoms and lack of anticipatory palliative care are contributory factors to high hospital death rates and patients being unable to die in their preferred place of death.
1.3The Department of Health document published in December 2004, “Securing proper access to medicines in the out-of-hours period” recommends prompt and easy access to palliative care medicines in the out of hours period (action points 8 and 9).
1.4Often towards the end of life patients cannot swallow oral medication therefore parenteral administration is required via a syringe driver to control symptoms. This medication needs to be available immediately to achieve the earliest symptom control. Therefore it is recommended that the regular GP / Independent Nurse prescriber, prescribes medication in advance of deterioration and that these drugs are left in the patient’s home. If a patient is being discharged home from acute or specialist care an adequate supply of anticipatory medications must be provided.
1.5This procedure covers all staff working for Health Partnerships. Due to NHS England organisational structures two Strategic Clinical Networks encompass Health Partnerships
- NHS Midlands and East – Nottinghamshire excluding Bassetlaw (CHP)
- Yorkshire and the Humber – Bassetlaw (BHP)
The treatment guidelines differ leading to some differences in this procedure.
2Policy Statement
2.1TheCommissioners and Providers support anticipatory prescribing and rapid access to medicines commonly prescribed in palliative care by ensuring a small stock of palliative care medications has been prescribed, packed and placed in the patient’s home in accordance with the Nottinghamshire End of Life Pathway for All Diagnoses and Individualised Plan of Care (Bassetlaw). The packs are targeted at patients reaching the terminal phase of their illness. It also supports effective team working between doctors, nurses and pharmacists, both in and out of normal working hours. The established Gold Standard Framework practice meetings are a useful opportunity to decide when anticipatory medication is placed in the person’s home. It aims to improve prompt access to symptom control for patients who are dying, contribute to the reduction of emergency hospital admissions for these patients and support those patients who choose to die at home.
3Equality Impact Assessment
3.1The organisation aims to design and implement services, policies and measures that meet the diverse needs of our service, population and workforce, ensuring that none are placed at a disadvantage over others. This procedure will not adversely affect any group on the basis of race, ethnic origins, nationality, gender, culture, religion, belief, sexual orientation, age or disability.
4The Scheme
4.1A community nurse in liaison with the general practitioner will identify adult patients requiring palliative care support in their home – using Gold Standard Framework meetings when possible. If it is anticipated that the patient’s medical condition may deteriorate into the terminal phase of illness and with the patient and carer’s agreement, the prescriber can prescribe a stock of anticipatory palliative care medication. The patient/carer will take the prescription to a community pharmacy to receive the dispensed medications. If the patient’s local pharmacy does not stock the required medications, a list of pharmacies that stock palliative medications can be obtained from the HP Medicines Management Intranet Site on the following link and click button Palliative Care:
nurse will document and put the medications in a container to be kept at the patient’s home for rapid administration of medicines commonly prescribed for breakthrough symptom control. All medicines will need to be authorised (prescribed doses, indication, directions, signed and dated) by the prescriber on the appropriate designated form (the prescription authorisation records for syringe driver medications currently used in the relevant locality – see Appendices 1 and 2 for completed examples), in order to enable a community nurse to administer the prescribed medication.
Patients being discharged from hospital will receive a supply of anticipatory medications as part of their Take Home drugs along with a signed administration instruction to ensure there is no delay.
5Known Risks
There are few known risks but:
5.1As with all drugs open to abuse, medicines supplies in patients’ houses may be open to abuse
5.2Patients and/or carers may misinterpret anticipatory prescribing as provision for euthanasia or cause increased anxiety that death is near, however good communication and established therapeutic relationships should allay fears.
6The Contents of the Palliative Care Pack
6.1The aim is to provide enough medication potentially to last for a 24-48 hour period e.g. if out of hours GP starts subcutaneous medication on a Saturday night there is enough to last until Monday morning when most GP surgeries and local pharmacies are open again. Doses need to be individualised. Below is a suggestion of dispensing quantities that may be prescribed in someone who is not already taking any of these medications. If patients are already on this medication orally or parentally, this would need to be taken into account when deciding the strength and quantity to prescribe.
Table 1
County Health PartnershipsMedicine / Strength / Quantity ª
Morphine Sulphate / 10mg/1ml / 5 x 10mg ampoules
Levomepromazine / 25mg/ml / 3 x 25mg ampoules
Midazolam / 5mg/ml / 6 x 10mg ampoules
Hyoscine butylbromide / 20mg/ml / 4 x 20mg ampoules
Table 2:
Bassetlaw Health PartnershipMedicine / Strength / Quantitya
Diamorphine / 10mg / 10
Haloperidol / 5mg in 1mL / 5
Midazolam / 10mg in 2mL / 10
Levomepromazine / 25mg in 1mL / 10
Hyoscine Hydrobromide / 400micrograms in 1mL / 10
Alfentanil / 500micrograms in 1mL (2mL ampoule) / 10
Oxycodone / 10mg in 1mL / 10
Water for injection BP / 10mL
Sodium chloride for Injection BP / 10mL
ª If patient is already on this medication then the quantity and strength needs to be individualised to ensure correct dose is available for parenteral medication.
7The Process
7.1Suitable patients
7.1.1A patient is identified as appropriate for a Palliative Care Medication Pack by a GP, community nurse, and non-medical prescriber; advanced nurse practitioner, nurse specialist or secondary care team. Co-ordination with team members is vital. Usually the pack is introduced in the last few weeks of life when patients become eligible for fast-track continuing care funding (equating to ‘yellow’ status on the GSF traffic light system: see Prognostic Indicators Guidance).
- CHP - Also the Nottinghamshire End of Life Pathway for All Diagnoses.
Palliative Adult Network Guidelines (PANG).
- BHP - Individualised Plan of Care (IPOC) Bassetlaw
Doncaster and Bassetlaw Palliative Care Formulary
7.1.2Some patients may be unwell but others may be relatively well at the time of initiation of the pack – their introduction should be reviewed regularly.
7.1.3A health care professional must have completed a risk assessment including assessing whether there are drug misusers who have access to the house. Consideration of which palliative care anticipatory medications it is appropriate to prescribe to patients whose homes are known to be accessed by drug misusers will need discussion within the General Practice multi-disciplinary team and Secondary Care team if being discharged from hospital.
7.2Patient consent
7.2.1The provision of a Palliative Care Medication Pack must be discussed with the patient and where appropriate the family and carers, in order to explain its function and acceptability.Where the patient has the capacity to consent, consent will be gained verbally, but it is recognised that a number of patients will have lost capacity to agree to the anticipatory supply of palliative care medications.
7.2.2In cases where an adult does not have the capacity to consent then consideration needs to be given as to whether provision is in the individual’s best interests. This would include discussion with relatives, carers or friends. For further information, see Mental Capacity Act 2005.
7.3 Communication with other teams
7.3.1The patient must have been referred to the Community Nursing team for nursing assessment and the introduction of Community Nursing notes into the home.
7.3.2Communication with the Out-of-Hours service must occur, stating “Palliative CareMedication Pack in patient’s house” in the Special Patient Information section of either the CNCS or the NEMS and Bassetlaw special patient notehandover form, depending which provider covers the patient. The special patient information form is completed by the GP or nurse.
7.4Prescription requirements
7.4.1An FP10 prescription is generated for the medicines contained in the Palliative Care Pack and signed by the GP or non medical prescriber caring for the patient. From acute care this will be via the patients Take Home Drugs supplied by hospital pharmacy. The correct quantities must be specified and prescriptions for parenteral morphine, diamorphine and midazolam are subject to Controlled Drug Regulations.
7.4.2It may be possible to incorporate this into a computer template; taking care to identify any patient specific issues e.g. allergies or interactions.
7.4.3The prescription must clearly state “In anticipation” for all medications (Appendix 3).
7.4.4A prescriptionfor morphine should typically contain the following instructions:
E.g. “Morphine sulphate 10mg/1ml, 5 (five) ampoules. Dose 2.5mg subcutaneously for pain.”
The dose, strength and number of ampoules need to be individualised.
In Bassetlaw Health Partnership Diamorphine is used in place of Morphine.
7.4.5A prescription for midazolam should typically contain the following instructions:
E.g. “Midazolam 10mg/2ml, 5 (five) ampoules. Dose 5mg subcutaneously for agitation.”
The dose, strength and number of ampoules need to be individualised.
As a guide for dosages please see:
- CHP - Palliative Adult Network Guidelines (PANG).
- BHP - Doncaster and BassetlawFormulary.
7.4.6This must include sufficient quantities for breakthrough doses to be dispensed.
8Collection & Delivery Arrangements
8.1The General Practice is responsible for writing the prescription when the patient is at home. However qualified non-medical prescribers can prescribe the medication with the knowledge of the GP. The patient/carer is responsible for taking the prescription to a community pharmacy.
8.2The medications should either be collected by the patient or their nominated carer, or they could be delivered to the patient’s home using the pharmacy’s delivery service where the pharmacy is able to offer this service. A prescription for controlled drugs is valid for 28 days but the patient/carer should be advised to arrange for the medications to be dispensed without delay.
8.3 As above patients being discharged from hospital will receive their drugs as Take Home medication
9 Storage of the Medications
9.1The patient’s Community Nurse is responsible for storing the medications in a suitable container provided for this purpose. This must be rigid, with a secure lid, light-proof and non-transparent. Palliative Care Pack containers provided to community nursing teams must be used where available. The medications need to be stored at the correct temperature.
9.2The nurse places the pack in a suitable location within the patient’s home out of reach and sight of children if there are children present in the house, accessible to the healthcare professionals caring for the patient.
9.3 The nurse indicates in the community nursing notes where the pack is located.
10Authorisation & Administration of Medication from the Palliative Care Pack
10.1Drugs from the pack cannot be administered by the Community Nursing team unless the medicines are authorised (prescribed doses, indication, directions, signed and dated) by a prescriber on the appropriate paperwork currently used in the locality.
10.2 The name of the medicine, batch number and expiry date should be checked prior to administration in the usual manner.
10.3 When a doctor or Community Nurse administers a medicine from the pack, the individual must complete the drug administration form / card.
11Using the Palliative Care Pack
11.1Only a healthcare professional qualified to administer medication and accountable to Health Partnerships for the care of the patient may administer a medicine from the pack.
11.2If the pack is opened and some of the medicines are administered, details should be recorded in the patient’s Community Nursing notes as usual.
11.3 If the pack is used by the out-of-hours team, the out of hours doctor or Community Nurse is responsible for informing the practice by telephone/fax or computer link the next working day that the pack has been opened.
12Checking the Pack
12.1It is the responsibility of the attending Community Nurses to check the contents of the packon use and this should be recorded in the Community Nursing notes. If the Community Nurses are attending frequently this does not need to be done more than once a week once the pack has been opened.
13Discrepancies Found when Checking Pack
13.1If a GP or Community Nurse finds that medications do not match the details on the drug administration card and or if the card has not been completed, the Community Nurse should attempt to identify who accessed the pack by checking the Community Nursing notes or checking with the practice.
13.2 If the Community Nurse finds any discrepancies not resolved by the above measures, then the Trust Incident Reporting Policy must be followed. Available at:
Also refer to CD SOP04 Dealing with Discrepancies Involving Controlled Drugs available at:
14Information Sheets
14.1 Medications are provided with the medicinal product’s patient information leaflets and the healthcare professional administering the medications must ensure the patient has access to the relevant leaflet.
14.2Information Sheets are also provided for:
- GPs and Community Nurses (Appendix 6)
15Pack No Longer Required
15.1When the patient has died it is the responsibility of the Community Nurse to collect the container, having removed any unused medications and recorded these in the patient record.
15.2It is the responsibility of the relatives or carer to return any unused medications to a pharmacy.
15.3The drug administration cardmust remain in the Community Nursing notes for tracking and audit purposes.
15.4The risk of contamination of the containers is low therefore cleaning the returned container with detergent is adequate.
16Audit
16.1Audit and evaluation of this policy across Health Partnerships will be encompassed in the:
CHP - End of Life Care Pathway auditing arrangements.
- BHP - Individual Plan of Care (IPOC) Bassetlawauditing arrangements.
17References
The Gold Standards Framework for Palliative Care
Department of Health, “Securing proper access to medicines in the out-of-hours period” December 2004
Nottinghamshire End of Life Pathway for All Diagnoses
Nottinghamshire Pharmacies that stock palliative medications
Mental Capacity Act 2005.
Palliative Adult Network Guidelines (PANG).
Doncaster and Bassetlaw Palliative Care Formulary (2014):
Individual Plan of Care (IPOC) Bassetlaw 2014
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HP Procedure for the Anticipatory Supply of Palliative Care Medications at End of Life